Full text of "Practical Lessons: The 1998 National Symposium on Homelessness Research"

See other formats

The 1998 National
Symposium on
Homelessness
Research

U. S. Department of Housing and Urban Development

U. S. Department of Health and Human Services

,1 SLRVlCfj

■4

/Moof)</o,J9.

Practical Lessons:

The 1998 National Symposium
on Homelessness Research

Prepared For:

Li : tivtfl

U.S. Department of Housing and Urban Developmnet

Office of Policy Development and Research

„siRV;c f .

U.S. Department of Health and Human Services

Office of the Assistant Secretary for Planning and Evaluation

Health Resources and Services Administration

Substance Abuse and Mental Health Services Administration

Edited By:

Linda B. Fosburg, Ph.D., Abt Associates Inc.

Deborah L. Dennis, M.A., Policy Research Associates, Inc.

August 1999

FOREWORD

Homelessness in America affects a diverse population: families with children, people with
disabilities, and others who flee from domestic violence or simply lose a job and cannot afford
decent housing. Despite substantially increased funding and attention by government agencies,
nonprofit groups, and thousands of volunteers, homelessness is still too common.

Much remains to be done. In the past few years, Federal, state and local agencies have created
partnerships that use a comprehensive approach to the housing and support services needs of
homeless adults and families with children. This new 'continuum of care' and other efforts to
coordinate and integrate government and local services have successfully restructured service-
delivery systems and improved our ability to respond to homelessness.

There has been a wealth of research over the past decade on homeless issues, including the nature
of homelessness and characteristics of the homeless population; the special needs of homeless
persons with disabilities; critical support services and other assistance homeless people need to
become more self-sufficient; and new approaches to the problem. This is a broad range of
important topics, and it is appropriate to review these findings carefully.

HHS and HUD collaborated to draw practical lessons from the studies. Leading researchers,
program managers, practitioners and consumers commented on, reviewed, and synthesized
knowledge about how to design continuums of care and how to provide services to homeless
persons most effectively. As a result of this work, we have developed Practical Lessons: The
1998 Symposium on Homelessness Research, a set of summary papers and topics for further
examination.

We are pleased to make this publication available to those concerned with and working to solve
these problems, with the hope that it will help us all reach our goal of ending homelessness in
America.

Andrew Cuomo Donna Shalala

Secretary of Housing and Urban Development Secretary of Health and Human Services

Table of Contents

Acknowledgements iii

Overview v

1. Demographics and Geography: Estimating Needs 1-1

By: Martha R. Burt, Ph.D

2. Special Populations of Homeless Americans 2-1

By: Robert Rosenheck, M.D., Ellen Bassuk, M.D., and Amy Salomon, Ph.D.

3. Homeless Youth: Research, Intervention, and Policy 3-1

By: Marjorie J. Robertson, Ph.D., and Paul A. Toro, Ph.D.

4. Making Homeless Programs Accountable to Consumers, Funders and the Public 4-1

By: Dennis Culhane, Ph.D., David Eldridge, M.S.W., Robert Rosenheck, M.D., and

Carol Wilkins, M.P.P.

5. Giving Voice to Homeless People in Policy, Practice and Research 5-1

By: Nicole Glasser

6. To Dance With Grace: Outreach and Engagement to Persons on the Street 6-1

By: Sally Erickson, M.S.W. and Jaimie Page, M.S.W., L.S.W.

7. A Review of Case Management for People Who Are Homeless: Implications

for Practice, Policy and Research 7-1

By: Gary Morse, Ph.D.

8. Balancing Act: Clinical Practices that Respond to the Needs of Homeless People 8-1

By: Marsha McMurray-Avila, M.C.R.P., Lillian Gelberg, M.D., M.S.P.H.,

and William R. Breakey, M.D.

9. Emergency Shelter and Services: Opening a Front Door to the Continuum of Care 9-1

By: Judith D. Feins, Ph.D. and Linda B. Fosburg, Ph.D.

10. Transitional Housing and Services: A Synthesis 10-1

By: Sue Barrow, Ph.D. and Rita Zimmer, M.P.H.

1 1. Reconnecting Homeless Individuals and Families to the Community 1 1-1

By: Debra J. Rog, Ph.D. and C. Scott Holupka, Ph.D.

National Symposium on Homelessness Research

12. What Do We Know About the Systems Integration and Homelessness? 12-1

By: Deborah L. Dennis, M.A., Joseph J. Cocozza, Ph.D., and Henry J. Steadman, Ph.D.

13. Rethinking the Prevention of Homelessness 13-1

By: Marybeth Shinn, Ph.D. and Jim Baumohl, D.S.W.

Appendix A- Agenda A-l

Appendix B - Biographies B-l

Appendix C - Participant List C-l

National Symposium on Homelessness Researcii

Acknowledgements

The editors of this report on the National Symposium on Homelessness Research: What Works — Linda
B. Fosburg and Deborah L. Dennis — thank many others for their valuable assistance in planning,
implementing, and reporting on the outcomes of the symposium. From the beginning in December 1997,
this project has been a team effort that has benefited from the collaboration of many other persons.

First, we recognize the invaluable contributions of two other core members of the planning team — James
E. Hoben and Mary Ellen O'Connell — the representatives of the cosponsors of the symposium, the
Department of Housing and Urban Development (HUD) and the Department of Health and Human
Services (HHS). We, as the core planning team, also thank the other planning team members — George
Ferguson, Jean Hochron, Walter Leginski and Marge Martin.

Second, we thank the members of the expert panel who reviewed the initial plans and provided important
input into the content and format of the symposium. Among those who participated in this activity were:
Martha Burt (The Urban Institute), Mary Ann Gleason (National Coalition for the Homeless), Steven
Hornburg (Fannie Mae Foundation), Paul Koegel (RAND Corporation), Betsey Lieberman (AIDS
Housing of Washington), Ann O'Hara (Technical Assistance Collaborative), Marjorie Robertson
(California Pacific Medical Center Research Institute), Debra Rog (Vanderbuilt University Institute for
Public Policy Studies), Nan Roman (National Alliance to End Homelessness), Robert Rosenheck (West
Haven Veterans Administration Medical Center), Amy Soloman (The Better Homes Fund), Julie
Sandorf (Corporation for Supportive Housing), Laurel Weir (National Law Center for Homelessness
and Poverty), and Beth Weitzman (New York University).

Third, we are grateful for the contributions of the Federal representatives who opened and closed the
symposium, including: Xavier de Souza Briggs (Deputy Assistant Secretary for Research, Evaluation,
and Monitoring at HUD), Margaret Hamburg (Assistant Secretary for Planning and Evaluation at
HHS), Fred Karnas, Jr. (Deputy Assistant Secretary for Economic Development, Office of Community
Planning and Development at HUD), and Marsha Martin (Special Assistant to the Secretary of HHS).
We also thank all the facilitators at the symposium: Ann O'Hara did a wonderful job as the overall
symposium facilitator; Linda Boone, James Hoben, Jean Hochron, Mark Johnston, Walter Leginski,
Gretchen Noll, James O'Connell, Mary Ellen O'Connell, Fred Osher, Fran Randolph, Amy
Soloman, and Jean Whaley provided the leadership for the facilitated discussions. We also
acknowledge and thank Donald Bradley of the Freddie Mac Foundation for providing scholarships to
allow formerly homeless persons to attend and for the reception at the end of the first day of the
symposium.

We give a special thanks to all of the authors of the research synthesis papers who provided the substance
for symposium. We also thank respondents to each of the research papers. The names of the authors and
respondents are shown in the agenda in Appendix A. We thank the staffs of Abt Associates Inc. and
Policy Research Associates who assisted us in all aspects of this project. Finally, we recognize the
contributions of all of the authors who have conducted the research on homelessness over the past two
decades. Their efforts are listed in the bibliographies of each of the research synthesis papers.

National Symposium on Homelessness Research

Overview

by
Linda B. Fosburg, Ph.D.
Deborah L. Dennis, M.A.

When passed in 1987, the Stewart B. McKinney Homeless Assistance Act (P. L. 100-77) was landmark
legislation providing the first federal funds targeted specifically to address the needs of homeless
persons. The McKinney Act originally consisted of fifteen programs providing a range of services to
homeless people, including emergency shelter, transitional housing, primary health care, education, and
some social service needs. By 1998, approximately one decade after the McKinney funds became
available and research results on the impacts of funding were becoming available, it was appropriate to
address the question — What works?

The National Symposium on Homelessness Research was convened in Arlington, Virginia on October
29 th and 30 th , 1998 under the auspices of the U. S. Departments of Housing and Urban Development
(HUD) and Health and Human Services (HHS) for this purpose. 1 Approximately 175 persons (including
researchers, practitioners, policymakers, and formerly homeless persons) attended. During the two-day
meeting, all in attendance had an opportunity to participate. Authors of eleven research papers presented
their findings. Facilitated discussion groups followed the research presentations. Designated
respondents provided prepared comments and other attendees gave additional feedback to the authors.
Plenary discussions were another source of feedback to the authors and symposium planners.
Consequently, the original papers were revised and the symposium planners commissioned two
additional papers for inclusion in this compendium of research papers on homelessness.

Planning for the symposium began in January 1998 by a HUD/HHS joint planning committee consisting
of representative from the two Departments and a team of two contractors (Abt Associates Inc. and
Policy Research Associates, Inc.). An expert panel, convened in March 1998, provided input on the
structure, agenda, topics, and participants for the symposium. Two complementary initiatives supported
the researchers efforts to synthesize the lessons and implications of research done on exemplary practices
for homeless people. One initiative, Workshop on Exemplary Practices: Addressing Homelessness and
Health Care Issues, sponsored by the U. S. Department of Health and Human Services, focused on what
is known about effective service delivery strategies and current policy questions. The second initiative,
the National Symposium on Homelessness Research sponsored jointly by HUD and HHS, incorporated
papers from the workshop, commissioned additional researchers to investigate what is known about the
effectiveness of various components of the continuum of care and what should be the emphases for future
research, and convened a national forum to discuss the resulting papers.

Common Themes Derived from the Research Papers

The Symposium was an historic opportunity to assess what we, as a nation, have learned about how to
address homelessness since the McKinney Act was enacted. While there is much that remains to be
understood about the effectiveness of programs for specific subpopulations of homeless persons, the

1 Three appendices accompany this report. Appendix A is the agenda for the symposium. Appendix B contains
brief biographies of the authors of the research papers. Appendix C is a list of all symposium attendees.

National Symposium on Homelessness Research

Overview

sentiment echoed by all in attendance was that we have learned a great deal about how to end
homelessness.

We know that outreach works. We know that subsidized housing works. We know that involving
homeless and formerly homeless people in the design and implementation of services is important to
creating successful programs. We know that homeless people sometimes have complex needs. We know
that case management and systems integration can help cement and support fragile interpersonal and
interorganizational relationships, creating greater opportunity for positive client outcomes. We know
that programs can be held accountable, that management information systems exist that can provide valid
information for planning and policy, and that the communities can reliably and feasibly assess the local
need for homeless services.

Some of the key themes that emerged from the papers commissioned for the Symposium as well as from
the ensuing discussion were the following.

Homeless People: Diversity and Local Need

• Homeless people reflect the nation's diversity and their special and sometimes complex
characteristics and needs must be identified, respected, and addressed.

• Despite their diversity, almost all homeless people are extremely poor. Regardless of their other
difficulties, practitioners must address their basic tangible needs for material resources.

• In addition to responding to basic needs for shelter, food, clothing, and medical care, programs
should begin with a systematic assessment of the unique needs of each homeless person.

• Homeless persons include families with children, single people, Veterans, runaway and homeless
youth, persons with mental health and substance abuse problems, and persons who are homeless for
purely economic reasons. Each group has distinct characteristics, needs, and preferences that should
be considered when designing programs.

• Some homeless persons will require limited assistance; others will require extensive and long-term
support. Over time, each person's needs will change and so should the necessary assistance.

• Homeless programs can help homeless persons to restore self-esteem, recover from illness, address
disabilities, develop life and economic skills, and attain maximum self-sufficiency. Achievement of
these objectives requires a partnership of individual effort and tailored assistance by the homeless
service provider.

• Each community must collect its own data on homeless needs. The numbers and characteristics of
homeless persons will vary by community and will change over time, based on regional economic
conditions and public policies.

Services:

Health care programs, which make special adaptations to the structure and delivery of health, mental
health, and substance abuse services, will be more effective at serving homeless people.

National Symposium on Homelessness Research

Overview

• Some delivery adaptations should include extensive outreach, mobile sites, procedural flexibility, and
follow up.

• Integration of primary care, mental health, and substance abuse services is the preferred approach for
providing services to homeless persons.

• Research has demonstrated that outreach services are effective in engaging those who are unserved
or underserved by existing agencies and those who unable or unwilling to seek services on their own.

• The employment of formerly homeless persons as outreach workers is an effective engagement
strategy.

• The most effective case management strategies for homeless persons include: conducting assertive,
community-based outreach; giving priority to client's self-determined needs; providing clients with
active assistance to obtain needed resources; maintaining small case loads; and using an assertive
community treatment (ACT) approach.

Housing:

• Receipt of affordable housing is the single greatest predictor of formerly homeless persons' ability to
remain in housing. Homeless persons, who receive subsidized housing, will for the most part, remain
in that housing. To afford private-market-unsubsidized housing, they will require increased income
and employment assistance.

• There is a large unmet need for affordable housing for homeless and very low-income Americans.
Intensive supportive services, especially for homeless persons with significant disabilities are also
greatly needed.

• Consumer choice in housing is associated with residential stability for formerly homeless people.
Thus, communities may need to offer a range of living options, with different degrees of social
control and expectations for behavior.

• In many places, emergency shelter has been expanded from "three hots and a cot" to include client
assessment, case management, and supportive services. The focus has shifted from shelter only to a
reintegration into the community.

• Descriptive data from national surveys of transitional housing find that about 70 percent of those
who completed transitional housing programs obtained housing. Despite the strong commitment of
many to transitional housing, well-designed studies of its long-term effectiveness are almost non-
existent.

• Providers are encouraged to experiment with new models of transitional housing that are "co-
located" with or "convert" to permanent housing. This may provide a way to help individuals and
families transition out of homelessness without the stigma and the repeated disruption of support
networks that some transitional housing approaches entail.

National Symposium on Homelessness Research vii

Overview

Systems Integration:

• Services integration (client-level strategies) and systems integration (administrative-level strategies)
must be undertaken at the same time in order for either to be effective.

• Systems integration must be pursued at the federal, state, and local levels.

• Three strategies are necessary for systems integration to occur: having a designated leader
responsible for systems integration; getting the key players and decision-makers to the table (and
keeping them there), and using a formal strategic planning process.

Program Effectiveness and Accountability:

• Programs for homeless persons are only effective if implemented in the context of a system that
includes adequate affordable permanent housing and supportive community-based services.

• Providers of homeless services need client-based, longitudinal, networked data systems to administer
effective continuums of care and to influence decisions about mainstream systems. The client
information system should contain information on client needs, services, and outcomes. Individual
client data must be kept confidential to protect privacy.

• Homeless programs must improve their ability to demonstrate accountability by documenting all
outcomes.

Research on Homelessness:

• A great deal can be learned about program effectiveness by asking homeless persons, formerly
homeless persons, and practitioners about what works, what doesn't work, and why.

• Evaluations of promising practices need to include longitudinal data collection and comparative
analyses of experimental and control groups with adequate sample sizes to support findings.

• There must be an increased effort to document practices in the field and to translate the practical
implications of research to the field in ways that speak to a non-research audience.

Consumer Involvement:

• Homeless and formerly homeless people can contribute in many ways to the planning and
implementation of programs and policies designed to help them.

• Consumer input in research studies and program evaluations also greatly enhances the design,
conduct and interpretation of results.

• There are many examples and models of how to involve consumers in policy, practice, and research.

viii National Symposium on Homelessness Research

Overview

Synopsis of Research Synthesis Papers

The symposium planning committee, with input from an expert panel, selected the topics for the research
papers because of their relevance to various aspects of homelessness and potential contribution to the
field. Hence, the research basis of the papers contained in this report varies from extensive to modest.
Eleven of the research papers were presented at the National Symposium on Homelessness Research.
After the symposium, the planners commissioned two additional papers (the third and fifth summarized
below) for inclusion in this compendium. Each paper contains a wealth of information from the
synthesized research that can inform future initiatives for homeless people by practitioners, policy
makers, and researchers.

Demographics and Geography: Estimating Needs

Martha Burt's paper synthesizes the findings of nine studies of homeless populations over the past two
decades. It describes the most comprehensive and latest data on important characteristics of homeless
persons. It also summarizes the methodologies used by various jurisdictions to locate and describe
homeless people and the factors that make them vulnerable to homelessness. The author documents that
homelessness will vary among communities regarding the numbers, types of persons, and needs. She
also states that different data sources may lead to different population appraisals and determinations of
services needs. Based on this premise, the author provides local jurisdictions with recommendations for
feasible and cost-effective methods to collect data on the local homeless population. The author
underscores the importance of local data for local decision making as follows: "Having your own data
eliminates local arguments about the existence of the problem and focuses attention on what to do about
it"(p.l).

Special Populations of Homeless Americans

Robert Rosenheck, Ellen Bassuk, and Amy Solomon review the research on the subpopulations of
homeless Americans and conclude that they represent of all segments of society. They are men and
women, old and young, families and single people, whites and minorities, rural and city residents,
persons with serious health problems and the able bodied. Some appear more vulnerable and in greater
numbers than might be expected by their numbers in the population alone: e.g., single males and
minorities. Despite their diversity, the subgroups share common needs. All are poor; they lack decent
and affordable "housing, and do not have an adequate income. The similarities and differences found by
the studies of the past 15 years are illuminating. They point out that despite the evidence of common
needs, some subgroups are seen as "deserving" while others are not. They conclude that the evidence
shows that services should be targeted by the needs of the specific individual, not by the subgroup
characteristics.

Homeless Youth: Research, Intervention, and Policy

Marjorie J. Robertson and Paul A. Toro review the research on homeless youth. According to some
estimates, at least 5% of youth aged 12 to 17 are homeless and most evident in metropolitan areas. While
the research conducted to date is limited, the authors have synthesized the extant literature and described
what additional information is needed to provide a more accurate and complete description of this
subgroup of homeless people. The authors describe characteristics of homeless youth using standard
demographics and include precursors such as family and residential instability and prior school
experiences. They also describe homeless youths' mental health, substance abuse, and health issues as
well as their survival strategies while homeless. The authors discuss the intervention strategies that have

National Symposium on Homelessness Research ix

Overview

been attempted after the youth have been homeless for some period. Although there is less literature on
prevention, the authors present two basic approaches to homelessness prevention through primary
prevention interventions and through prevention of repeated spells of homelessness. Finally, the authors
provide recommendations for future studies using large representative samples of homeless youth, valid
and reliable measurement tools, and assessment of both the youths' strengths and problems.

Making Homelessness Programs Accountable to Consumers, Funders and the Public

Dennis Culharie, David Eldridge, Robert Rosenheck, and Carol Wilkins address the question: Are
programs for homeless people delivering on their promises? This paper explores how performance
measurement can provide program effectiveness indicators to consumers, funders, and the public, to
improve programs. For example, consumer outcomes can inform whether consumer services are being
delivered and consumer needs are being met. Program outcomes can provide funders with the
information needed about future funding decisions. System outcomes can likewise provide the public
with the information needed to ensure that community goals are being reached. The authors review the
measurement strategies that can be used, ranging from simple and inexpensive to more complex and
resource-intensive. They describe standard assessment tools that have been used at the three levels of
accountability. Finally, they discuss the benefits of a cost benefit analysis, especially for homeless
programs where cost comparisons with those of other institutions (e.g., hospitals, jails, mental
institutions, etc.) can help to ensure continuing public support. They conclude that standardized
information is a necessary basis for discussing the merits of existing and proposed policies and programs.

Giving Voice to Homeless People in Policy, Practice, and Research

The author of this paper, Nicole Glasser, brings her personal experience to this research assignment. She
states: "Having personally walked many high roads and low roads as a consumer of mental health and
homeless services, nothing makes more sense to me than allowing clients, or consumers of services to
have a greater say in their services — from the direct provision of services, to policy, administration, and
evaluation." Consumer involvement in programs that serve homeless people has been growing. There is
an increasing body of literature that supports the benefits of consumer involvement on the programmatic,
policy, and administrative levels. Consumer empowerment ranges from participation in a community
meeting or on an advisory board, to hiring consumer staff, to completely consumer-run programs and
organizations. While there is resistance within any system to hand over power to a stigmatized group,
once done, the system may find that it has higher quality and more responsive services. Research finds
that consumers can perform as well as non-consumer staff and are especially skilled at engaging potential
clients. Within consumer-run organizations, the focus of service delivery is on choice, dignity, and
respect. There are a number of things that federal; state and local governments can do to encourage
consumer involvement in decision-making, staff hiring, and the creation and survival of consumer-run
organizations.

To Dance with Grace: Outreach and Engagement to Persons on the Street

Sally Erickson and Jaimie Page review the literature on outreach. By definition, outreach is the process
of connecting or reconnecting a homeless individual to needed services. Much of the extant literature
comes from mental health outreach programs. Because homeless populations vary by community, each
community must tailor its outreach program to those in need. The authors cite several principles of
successful outreach programs. These include: focus on individuals as people, recognition of the
uniqueness of each individual, emphasis on empowerment and self-determination for homeless persons,
delivery of outreach services with an attitude of respect, hope, kindness, advocacy, as well as flexibility

National Symposium on Homelessness Research

Overview

and creativity. One of the developments in outreach, cited by the authors, is employment of
consumers/peers/formerly homeless persons as outreach workers. Success stories in outreach abound,
yet funding remains an outstanding issue. The authors encourage communities to include outreach
explicitly in their Continuum of Care proposals.

A Review of Case Management for People Who Are Homeless: Implications for Practice,
Policy, and Research

Over the past two decades, case management has become one of the most common practices in the
delivery of services to homeless people, according the author, Gary Morse. Confusion over what
constitutes case management abounds. To clarify, the author discusses several functional definitions of
case management. He also presents case management approaches and models for various client
subgroups and specialty areas. He concludes from his synthesis of studies on case management that there
is strong support for the effectiveness of case management to help homeless people with severe mental
illness into needed services, including stable housing. Frequent service contacts are critical to treatment
retention and housing outcomes. Case management services are less effective with some clients than
others. He also cites knowledge gaps about the effectiveness of case management for those with dual
diagnosis, children, youths, women, or families; other mental disorders that are not classified as severe
mental illness. Finally, he examines exemplary case management practices in terms of: staff skills and
abilities, service principles, and organizational practices; and make recommendations for promoting
exemplary practices

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

The occurrence of physical and/or mental illnesses is approximately two to six times higher for homeless
people than for those who are housed (Wright, 1990). According to the authors, Marsha McMurray-
Avila, Lillian Gelberg, and William R. Breakey, both types of illnesses have been implicated as "causes
and consequences of homelessness for many individuals" (p. 2). This is because the incidence of these
illnesses creates vulnerabilities that can lead to the primary causal factors of homelessness: loss of
income and home. After over a decade of practice with homeless populations, there is a growing
agreement on what constitutes state-of-the art delivery of clinical services with homeless persons. The
authors cite nine general principles that have emerged and discuss outcomes in terms of system-level and
client-level outcomes. They conclude: health care programs need to be expanded into other areas (e.g.,
dental health); more extensive data on health care utilization, costs, and outcomes need to be collected;
and retention programs for skilled practitioners to work with homeless people are needed.

Emergency Shelter and Services: Opening the Front Door to the Continuum of Care

Judith Feins and Linda Fosburg review the provision of emergency shelter and services to homeless
persons in the U. S. They focus primarily on the Emergency Shelter Grant (ESG) program, which helps
localities and states provide facilities and services to meet the needs of homeless people and, at the same
time, aid in their transition from temporary shelter to permanent homes. In large part, this paper grows
out of an evaluation of the ESG program conducted in 1993. Today's emergency shelters provide many
more services than "three hots and a cot" (or three meals and a bed). Nearly all ESG-supported shelters
provide one or more supportive services to clientele. The authors describe the populations served and the
effective practices used in delivering emergency shelter and services. The authors conclude that the
problem of homelessness is not likely to disappear soon. More research emphasis needs to be placed on
both ends of the continuum of care, especially on effective strategies for homelessness prevention and
programs to ensure a transition to stable economic self-sufficiency.

National Symposium on Homelessness Research

Overview

Transitional Housing and Services: A Synthesis

According to Susan Barrow and Rita Zimmer, in 1994, when the U. S. Department of Housing and Urban
Development first required applicants for federal funding of homeless programs to create a continuum of
care, transitional housing became a "required" element of a comprehensive response. The authors
discuss the boundaries among transitional housing, emergency shelter, residential treatment programs,
and permanent supportive housing. They also examine the ways that typical programs vary, especially in
terms of program outcomes in five categories: service engagement and utilization, behavioral measures,
self-sufficiency measures, housing variables, and cost effectiveness. The authors conclude that
transitional housing can be effectively implemented only in the context of adequately subsidized
permanent housing and readily available supportive services. They also conclude that comparative
research is needed between transitional housing models and other alternatives. Furthermore, more
emphasis should be placed on consumers' perspectives, especially their attitudes toward acceptance of
services as a condition for remaining in housing.

Reconnecting Homeless Individuals and Families to the Community

Debra Rog and Scott Holupka characterize the circumstance of homelessness as personal isolation and a
lack of connections with family, jobs, and community. This paper explores what is known about
reversing the process and reconnecting homeless people with their personal self-sufficiency, with
residential stability and employability, as well as with family and friends. The authors explore what has
been learned about various aspects of the process. First they discuss the reconnection process to
residential stability and describe several program strategies (e.g., Supportive Housing Program, Shelter
Plus Care, and Section 8 Moderate Rehabilitation Assistance Single Room Occupancy) and evidence of
effectiveness. Next, they explore the process of reconnecting homeless people with the job market
through a variety of program strategies (e.g., Job Training for the Homeless Demonstration Program, and
Next Steps: Jobs). The authors also discuss the research on reconnecting with family and friends. They
conclude that the best prospects for success may be a "three-legged stool" approach that encompasses
housing, services, and employment.

What Do We Know About Systems Integration and Homelessness?

Deborah Dennis, Joseph Cocozza, and Henry Steadman maintain that despite calls for comprehensive
systems of care for homeless people over the past decade, little has been done in this regard. The authors
define and differentiate between systems integration strategies (e.g., involvement of interagency
coordinating bodies, strategic planning, and pooled or joint funding) and services integration strategies
(e.g., involvement of case management, individualized service planning, and assertive community
treatment). They demonstrate with numerous examples how communities have addressed systems and
services integration and made it work for them. They conclude that successful systems integration
requires the commitment of key decision-makers to an on-going process and the resources required to
implement an effective system. Both systems and services integration strategies must ultimately be
implemented simultaneously.

Rethinking the Prevention of Homelessness

Marybeth Shinn and Jim Baumohl review the current state-of-the-art in homelessness prevention and
draw the same conclusion as the U. S. General Accounting Office (1990) did; it remains "too early to
tell" what works in preventing homelessness. The authors discuss the logic of prevention and the basic
definition of what is included in homelessness prevention. Next, they critique the conceptual and

xii National Symposium on Homelessness Research

Overview

methodological problems. For example, while eviction prevention programs appear effective in some
instances, they may be excluding people who are at higher risk of homelessness — those who do not have
a lease, but who are precariously housed. Similarly, programs that target discharge planning or
amelioration of domestic conflicts — even if 100% successful — may only reach a small proportion of
those who are likely to become homeless in a given year. The authors conclude that while social services
may be valuable for other reasons, services may not be the essential factor in preventing homelessness
once access to subsidized housing is taken into account. Instead, the authors propose testing other
models of homelessness prevention and point to the need for long-term followup. Otherwise, the
ultimate results of a homelessness prevention program will remain inconclusive.

Summary

In summary, the thirteen research papers contained in this report offer many insights into what has been
learned in the past two decades. Indeed, we have learned a great deal about how to end homelessness.
Each of the papers offers its views on the emerging best practices and provides appropriate cautions
where improved practices need to be developed and integrated into the current strategies for addressing
the needs of homeless people.

National Symposium on Homelessness Research xiii

Demographics and Geography: Estimating Needs

by
Martha R. Burt, Ph.D.

Abstract

This paper summarizes the latest and/or most comprehensive data on important characteristics of
homeless people. It looks at the demographics and distribution of homeless people among communities
of different types, as documented by a range of research methodologies in various jurisdictions and
nationwide. It also examines how characteristics may differ depending on the locations in which a study
looked for people to include, and factors that seem to make people vulnerable to homelessness.

The paper then turns to the need of local jurisdictions for information to help with service planning. It
discusses the variety of people and agencies that might need information for planning, the types of
decisions they must make, and what types of information would help them the most. It continues with a
review of several strategies that work at the local level for collecting the most useful data, and the
advantages and disadvantages of each method. Finally it draws the conclusion that every jurisdiction
will be best served by gathering its own information about service needs for planning purposes.

Lessons for Practitioners, Policy Makers, and Researchers

The best national and local studies of homeless populations show highly variable results for

most demographic characteristics, including gender, age, race, ethnicity, household structure,

and length of homelessness.

No national data source will ever exist that can provide adequate information for local

planning.

Each jurisdiction should gather its own data on population characteristics and service needs.

Local data are the only data that are truly useful for local planning.

Feasible and reasonably-priced ways exist for local jurisdictions to collect their own data.

More and more jurisdictions are doing so.

Having your own data eliminates local arguments about the existence of the problem and

focuses attention on what to do about it.

What you learn about the characteristics and need of your jurisdiction's homeless population

will depend on where you go for information. If you go only to shelters you will miss a lot,

even if you have a shelter tracking database that provides unduplicated data over time.

National Symposium on Homelessness Research 1-1

The contents of the papers for the National Symposium on Homelessness Research are the view of the author(s) and do not
necessarily reflect the views of the U.S. Department of Housing and Urban Development, the U.S. Department of Health and
Human Services, or the U.S. Government.

Demographics and Geography: Estimating Needs

Introduction

This paper starts with a summary of the latest and/or most comprehensive data on important
characteristics of homeless people. It looks at the demographics and the distribution of homeless people
(at a single point in time) among communities of different types. It also examines how characteristics
may differ depending on the locality where people are found, and factors that seem to make people
vulnerable to homelessness.

It then turns to the issue of what might be meant by "need". It discusses the variety of people who use
information on needs among homeless people to make planning decisions, the types of decisions they
must make, and what types of information might help them the most. The paper concludes by reviewing
several strategies for obtaining data at the state and local levels, and the advantages and disadvantages of
each for the various decision makers.

What Recent Studies Say

Who Are Homeless People?: I
Demographics and Patterns of Homelessness

Many studies have collected descriptive information about homeless populations over the past two
decades. Most are studies of particular cities or parts of cities, and some analyze only the information
from people staying in a single shelter. Some have specialized purposes such as examining the nature
and extent of mental illness or substance abuse or the situations of homeless families, while others are
quite general. No attempt has been made to summarize all of these studies. Rather, several of the most
recent studies that have methodological interest, cover sizeable geographical areas, and provide
overviews of homeless populations are reviewed.

Table 1 summarizes these studies, which include one that covers the entire United States (1990 Census S-
Night), three of specific cities (New York, Philadelphia) or parts of cities (Los Angeles), one that is
representative of all cities over 100,000 in the United States, one that covers an entire major
Metropolitan Statistical Area (Washington, DC), two that provide important new information on
homelessness in rural areas (Ohio and Kentucky), and one that summarizes studies on family
homelessness. To help in interpreting the basic demographic information shown in Table 1, the table
also includes the year(s) in which the studies were done, the types of venues where the studies located
their respondents, and the methodological approach used. Gender (percent male), race/ethnicity,
education (percent high school graduate or more education), whom respondents are with, and length or
patterns of homelessness are the demographic and descriptive data examined in Table 1 .

1-2 National Symposium on Homelessness Research

^ oa

T-H

»*> J, M

.^ s a* oi

$ 1 E c

2 C J" ti
O « © ti

ctf fa S3 Ji

1
IT)

00
ON

1-H

9
_o

9
_o
'C

•Si*

B _

2 M

>B b

3 >

•— \

ON
ON

C/5

«- 3

C «S

S 4) "tt b

9 t,

fa.

4) « 3 4)

V5 — © (/)

i i

00 On
NO f>

IE
O

1c 73

O .2

■a 1

3 O

d o

i-H

H
Z

c o >

O fe «

Gfl

Q
*

w>
_c

^ u

.■£ "~1 "1

"o y «

Q.Q .2 _
i « § u

4) 1) 5 \3
r- Uh O .3
C S3 O O

0\
ON

•-a .-a .a

S © 2 S

E js o -g

U O & It

"5.

01
«

«
u

B
0)

fa
Q

2 *

*o
«3

ULT RESP

Jm 0>

12 w

— £

IS 3

ft- u

ON
i

I— 1

go S^
u B «J

s a -s

— an

■a 2 JS

ON
IT)

a Q

j <

J- *

u *

5 £

> a

h B M
« 3 X!

5 s
Z U

Z U

41 S3 IS

IT)

C/l

0) >>

WD 3
C 05

OX) >

c o

73
0>

-o .2

S
_©
'S

a
u

_©

< x

fa U

< e

73 ^

o O

fa "O

a y a —

E 2 b ^

w — ^ —

91 (3 Di fl

J3 « ©

q-i

73 +

<u o

■43 O

■s °.

01
<*■»

S 9

« .ts
fa £

.2
oo

00
ON

ai~

1 * m
5 01 ™

13 U g WD
B « .5 O

5 s ~ •- S

u tn cj Q,

a
IS

-J2 B 2

g ale «>

'3 s, i> b.

2
fa

£2 ID
C OS

B
01

<Sl

9
S

■v

'SJD

_4j

"o
U

1*
© u

•O S3

o
u

-a
s
■*^

O ©

wo
o

J- L>

"S-S

s <

0) S3

O E

<D
w

w
w

CO
CO

_a>

E
o

X
c
o

E
=s
'co
o
a.
E

"ro
c
o

-z.

« 3 E c
2 C g w
O es © "J

I-H

ON IT) f}

X ta X «

H 4 N !

9
45

v
*

n V)

<-H 00 -H <s

Is
O

O iri

HX^N

o
as

H
Z

r- ^h s© !

2 *

Oh
CO

— " V
■S 3

- J

00
00

2 "3
ft- U

^5 oo jn ^h
* ^ w o

w Q

J <

J* eg

« to

IT) Tt

N© fS

4. S
Z U

55 as on 3

v© i/> rj ^h

DC S

00 ^H Tt

J u

I/) N H 00

e s
« .-5

ft.

■2 *■*

^h v© e

* t H C)

Gfl

neMOo

■^ ^ i-H i-H

ft.

~ E

.a •< «
Is '3 L

S J3 <u 03 J"

a .a £ a. a
f: '& 3 .sa a

« < £ a o
« ^ ^ ^ ^

■a

"C
o
en

« ©

cj ON

JS 4>

£ c

JS" o

S TS

« a

u a.

B- JS

3 "S

— . «

"§1

Z%
§ 3
V 12

3 s

-2 g

.a '«
a 4

M 2

°- £
.2 s

a «

3 S
«2 3

y-g

* o
u

. u

4) .^

5.1
n *r

o-S

® 1

*^ Q-

*" mi

< |

II 4>

r. U)

fe 2
i > '

a a

O 41

I- XI

a £

«3 .3

4> W
JC *
u *

S-'S

§£

11 g <^

« ^§; '

CO - ^

12 3 eV'

4> J3

£ O M
CO 2 3

11 r s

«a

Demographics and Geography: Estimating Needs

Basic Demographics

Looking first at gender, males as a proportion of the homeless population range from a high of 83 percent
(in Los Angeles) to a low of 39 percent (rural Kentucky), excluding for the moment a consideration of
the family homelessness studies reviewed by Rossi. The statistics on gender from the Table 1 studies
lead to the generalization that the more urban/central city a place is, the higher the proportion male
among the homeless population. Conversely, the more suburban/rural a place is, the higher the
proportion female, largely due to the higher ratio of families to singles in the suburban/rural jurisdictions.
New York and Philadelphia appear to be the exceptions to this generalization, probably because New
York unlike most cities really does have a high ratio of families among its homeless population even at
single points in time, and the Philadelphia database probably misses many of the single men who use the
biggest shelter. The studies reviewed by Rossi, concerned as they are exclusively with family
homelessness, report much lower proportions of adults who are male.

Race/ethnicity varies considerably among the Table 1 studies, owing largely to the variation in the racial
and ethnic composition of the communities where the studies were conducted. Regardless of location,
however, African-Americans are significantly overrepresented among homeless people compared to the
general population. Compared to 12 percent of the U.S. population who are African- American, the
Urban Institute's 1987 study found that 41 percent of homeless people in large U.S. cities were African-
American (and not Hispanic) while the 1990 S-Night counts in shelters found that 41 percent of the
people enumerated were African-American (including those who were also Hispanic).

People of Hispanic origin do not appear to be consistently overrepresented among homeless populations.
For instance, DC*MADS found 5.9 percent of the homeless population to be Hispanic compared to 5.2
percent of the total 1990 population of the Washington, D.C. MSA, and Culhane and colleagues
(Culhane, et al., 1994) report that 3.4 and 27.2 percent, respectively, of Philadelphia and New York
shelter users over a three-year period were Hispanic, compared to 1990 Hispanic populations of 5.6
percent in Philadelphia and 24.4 percent in New York City.

There is substantial agreement among the studies as to the educational achievement of respondents, with
52-62 percent having completed high school or a higher level of schooling. With respect to whether
people were homeless by themselves, with children, or in some other arrangement, studies differ but
there is some systematic variation we can account for. Urban studies that went beyond shelters to
include substantial parts of the street population found that single men comprised three-quarters or more
of the "households." The more rural the location of the study, the larger the share of households that are
families with children. Also, when one relies on shelter data only, as in the case of the New York and
Philadelphia tracking data bases, the proportion male declines and the proportion of families with
children (most headed by females) goes up. When a data source leaves out the relatively large proportion
of single homeless men who do not use shelters or, as in the case of Philadelphia, does not count the
shelter use of the most erratically shelter-using single men, the omission distorts the picture of household
structure among homeless people.

Homeless youth are one part of the homeless population often missing from policy consideration. Most
studies of homeless populations do not include a significant number of youth homeless on their own,
both because most of the venues where studies go to find homeless people serve only adults, because
many homeless youths are reluctant to use services at all, and because it is difficult to identify homeless
youth with other study techniques. Estimates of youth homelessness are often given not as point-in-time
estimates but as "homeless within the past 12 months" estimates, and range from about half a million to a
million and a half (Ringwalt et al., 1998). Ringwalt et al. (1998) used recent data from youth interviewed
from households living in conventional dwellings for the Youth Risk Behavior Survey to estimate that 1 .6
million youth ages 12 to 17 (7.6 percent [+ 0.7 percent] of the population in this age range) had a

National Symposium on Homelessness Research 1-5

Demographics and Geography: Estimating Needs

homeless episode of at least one night's duration within the 12 months before being interviewed. Only
about 2 in 5 of these youth said they used shelter services during their homeless episode.

This review makes clear the great extent to which basic information about homeless people varies by
geography and also depends on the venues from which people are interviewed or data are assembled. It
is very important for decision makers to be fully aware of the inclusions and omissions in the data they
use for planning, because different data sources (e.g., shelter only, shelter and other services, or services
plus "street" sources) may lead to quite different assessments of population characteristics and hence of
need.

Length and Patterns of Homelessness

The studies in Table 1 report their sample members' length of homelessness or patterns of homelessness
quite differently. Some report the length of time that people have been homeless during their current
spell, some divide their sample into groups such as chronic, episodic, and transitional/crisis/first time.
Findings vary considerably, but some generalization may be possible. However, to interpret the
length/patterns data correctly, it is necessary to leave out the New York/Philadelphia tracking database
information for the moment. Looking first only at the point-in-time data, it appears that we can say four
things: (1) long spells (more than 1 year) and or chronic homelessness characterize urban samples much
more than they characterize rural areas; (2) in urban areas about 40 percent or more report long current
spells; (3) more people in the rural than in the urban samples are in their first spell of homelessness, and
these are quite short; and; (4) the higher the proportion of families in the study, the shorter the spell
length or the more short spells are reported.

Looking next at the New York and Philadelphia data, it is clear that these multi-year unduplicated data
show quite the reverse of these generalizations. Indeed, the vast majority of the homeless population
(using shelters) in these cities are transitional (first-time or short-term). With the advantage of
unduplicated data covering several years, the New York and Philadelphia results make very clear the
dangers of relying on point-in-time data to describe what proportions of the homeless population have
spells of different lengths or different patterns of homelessness. Point-in-time data will always be biased
toward showing higher proportions of longer spells. When planners use point-in-time data, which they
most often will because that is all they can get, it is very important to try to compensate for its biases
toward long spells and away from short ones. If this is not done, the whole system of homeless services
may be structured in ways that are not in tune with the needs of the people coming for assistance.

Who Are Homeless People?: II
Predisposing Conditions and Experiences

Quite a number of studies, both longitudinal and cross-sectional with comparison data, have documented
strong associations of negative childhood experiences with homelessness (Bassuk, et al., 1997; Caton et
al., 1994; Herman et al., 1997; Koegel, Melamid and Burnam, 1995; Mangine, Royse and Wiehe, 1990;
Susser, Struening and Conover, 1987; Susser et al., 1991; Weitzman, Knickman and Shinn, 1992; Wood
et al., 1990). The most common childhood experiences associated with a higher risk of experiencing
homelessness are: histories of foster care and other out-of-home placement, physical and sexual abuse
(which often precede out-of-home placement), parental substance abuse, and residential instability and
homelessness with one's family as a child. These experiences are much more common among people
who have been homeless as adults than among people who have not.

In addition to evidence that risk factors from an individual's childhood predispose to homelessness, an
important new type of research documents the contribution of certain environments to homelessness even

1-6 National Symposium on Homelessness Research

Demographics and Geography: Estimating Needs

after taking into account the characteristics and histories of those who become homeless while living in
these environments. Culhane, Lee and Wachter (1996) analyze the addresses of families applying for
emergency shelter in New York City and Philadelphia, and find them much more concentrated
geographically than poverty in general. (Culhane has recently obtained similar results for the
neighborhoods of origin of homeless families in Washington, DC.) Neighborhoods producing high levels
of family homelessness have high concentrations of poor African-American and Hispanic female-headed
households that include children under six years of age. The housing is the poorest in the city, and
despite the fact that rents are the lowest available, residents still cannot afford them, with the
consequence that housing is overcrowded and many families double up, even though apartment vacancy
rates are high. These conditions create a large pool of families at risk of homelessness, from which it
only takes a small percentage every week to fill the available homeless shelters.

Where Are Homeless People?

The matter of "where" homeless people may be found can have several interpretations. The first
examined here is: how are homeless people distributed geographically among central cities, the suburbs
and urban fringe areas that make up the balance of the territory within Metropolitan Statistical Areas
(MSAs), and rural areas (outside of MSAs)? The second is how homeless people are distributed among
types of services and street locations within communities.

Geographic Distribution

Only a few studies exist that can shed light on the issue of geographical distribution because only a few
studies include any geographical diversity in their sampling. The 1990 Census counts of people in
emergency, domestic violence, and youth shelters on the night of March 20-21, 1990, which was done on
a single night and treats everyone, including children, as individuals, found 75 percent in central cities,
1 8 percent in suburbs and urban fringe areas (the parts of MSAs that are not central cities), and 7 percent
in rural areas (Burt et al., 1993— these figures do not include anyone counted in the "visible in the streets"
part of the 1990 Census). This compares to the overall 1990 U.S. population distribution of 32 percent in
central cities, 43 percent in suburbs and urban fringe areas, and 25 percent in rural areas.

In Kentucky's 1993 study, one of the few that covers a whole state and goes well beyond shelters), 21
percent of homeless individuals were found in the three major urban areas of Louisville, Lexington, and
Covington which have 25 percent of the state's 1990 population, while 79 percent were found in the
remaining 117 counties of the state where 75 percent of the population reside. 1

In DC*MADS, Washington, D.C. accounted for 77 percent of homeless and transient individuals, with
the remainder found in the suburbs and urban fringe (no areas were included in the study from outside
the MSA). In the Washington, DC MSA as a whole, only 15 percent of the population is located in
Washington, DC.

Everyone expects to find more homeless people in highly urbanized areas than in suburban and rural
areas, but it is also true that the rate of homelessness per 10,000 people has been shown to vary
considerably even when one considers only homelessness in large cities. DC*MADS estimates produce
a homelessness rate of about 150/10,000 population for Washington, DC and a rate of about 33/10,000
for the whole DC metropolitan area. Using Shelter Partnership's estimate of 80,000 to 90,000 homeless
people in Los Angeles County produces a homelessness rate of 88/10,000 to 99/10,000 for the county as

The number of homeless people in Louisville is probably underrepresented by these data, because Louisville reported only its
sheltered population at a point in time, it did not use the overall study method of a two-month data collection period and a
variety of agencies, nor were there searches of outdoor locations in Louisville.

National Symposium on Homelessness Research 1-7

Demographics and Geography: Estimating Needs

a whole in the late 1990s. Burt (1992a) obtained rates for U.S. cities with 100,000 or more population in
1986 ranging from under 10/10,000 up to 65/10,000 (average = 18/10,000) based on the number of
shelter beds available in the city rather than on actual estimates of homeless people. This magnitude of
variation strongly suggests the wisdom of having one's own local data rather than relying on national
averages.

What Services Do Homeless People Use?

A second way to think about "where" homeless people are is to think about the services they might use,
and therefore where they might be found within a community. Important locations where people might
be found include streets, outdoor locations, and other locations "not meant for human habitation" (for
short, "the streets"). Although the streets are not a service, one important issue for planning is how many
homeless people are being missed if one focuses one's data collection efforts only on those who use
services, and what types of services they might need. This was a very serious problem when studies went
only to shelters, or attempted to augment shelter-based data collection with a street component, because
street searches are almost always unsatisfactory. Often they do not locate many people, and they become
more dangerous to do the more thoroughly one tries to get to the most hidden places. So the problem is,
what is a safe and comprehensive way to include homeless people who do not use shelter services in data
collection?

A breakthrough, not less helpful because it was serendipitous, occurred in our ability to include a large
part of the non-shelter-using homeless population in data collection when studies began including soup
kitchens and other feeding programs in their service samples (1987 Urban Institute study, DC*MADS).
As we learned when this happened, many currently and formerly homeless people who do not use
shelters do come to soup kitchens. The 1996 National Survey of Homeless Assistance Providers and
Clients (NSHAPC— Tourkin and Hubble, 1997) extended this concept even further to include a wide
variety of homeless assistance programs, and the Kentucky Housing Corporation went well beyond
homeless assistance programs in its efforts to locate homeless people.

Results from several of these studies are telling. In the 1987 Urban Institute study, 36 percent of
homeless adults and 22 percent of children in homeless families used both shelters and soup kitchens in
the week before being interviewed. Thirty-two percent of homeless adults and 73 percent of children in
homeless families only used shelters, and 29 percent of homeless adults (but only 5 percent of children in
homeless families) used only soup kitchens in the past week (Burt and Cohen, 1989, p. 37). Thus
inclusion of soup kitchens in the study design increased the coverage of non-shelter users considerably.

DC*MADS added a soup kitchen component to its design after finding very few people in the street part
of its original shelter/street design. The resulting ability of DC*MADS to map the overlapping
movements of its respondents produced very interesting patterns. Fifty-six percent of respondents had
used a shelter within the previous 24 hours, 65 percent had used a soup kitchen, and 21 percent had spent
time on the streets. The overlap of these populations was considerable, with 27 percent using both
shelters and soup kitchens. Of all the respondents to DC*MADS, only 7 percent would not have been
found if the study had left the street component out entirely and gone only to shelters and soup kitchens
(Bray, Dennis and Lambert, 1993, p. 3-3). This was true for the entire literally homeless population in
DC*MADS, as well as for the population including transients.

The degree of population coverage achieved by DC*MADS through its shelter and soup kitchen
components is very encouraging, but must be qualified in several ways. Even within DC*MADS,
subgroup analysis revealed that coverage was somewhat worse without the street component for some
groups. The people least likely to be captured were heavy alcohol users, about 15 percent of whom
would have been missed without the street component. On the other hand, coverage for those with drug

1-8 National Symposium on Homelessness Research

Demographics and Geography: Estimating Needs

use during the month of the survey was actually better than for the sample as a whole (over 95 percent).
Other evidence for differential coverage by population subgroup comes from the Course of Homelessness
study in Los Angeles, where only 16 percent of young, single men on the west side of Los Angeles would
have been captured with a design that relied only on shelters and soup kitchens, without a street
component (Koegel, personal communication, 1996).

A final caveat is that DC*MADS achieved its level of coverage using a homeless-specific service-based
approach in an environment where many homeless-specific services are available. In environments
such as many suburbs and rural areas where homeless-specific services are scarce or nonexistent, such an
approach would clearly miss almost everyone. In these environments more and different types of service
agencies would have to be incorporated into the design to achieve adequate coverage, as was done in
NSHAPC and in the Kentucky statewide study. Even then, the Kentucky Housing Corporation
augmented its service-based approach with a targeted search of outdoor locations.

Limitations of the Data

Many of the studies reviewed in Table 1 used quite sophisticated methodologies, and produced elegant
and reliable results. However, they were very expensive to conduct and, while they may be helpful at the
national level and to answer particular research questions, are of limited utility to local planners. The
most important lesson to be learned from these studies is that even expensive, methodologically
sophisticated studies cannot produce consistent findings because the reality of homelessness varies a
good deal with the geographic location of interest. Therefore, local decision makers should make every
effort to collect their own data using less perfect but "good-enough" methods, collect it with sufficient
regularity and thoroughness that it becomes a useful tool for decision making..

What Planners Need To Know About "Need"

Information for Planning: Who Needs What?

Many people may be involved in planning homeless service systems or in estimating how much service is
needed at a given time. Table 2 shows the variety of people who plan, from administrators in direct
service programs up though the staff of federal government agencies. It also shows the things they may
plan for (column 2) and the information that might help them accomplish this planning, together with the
sources that might provide the information (column 3).

Simple Planning

Planning may be very simple, such as predicting how many meals to prepare, how many cots or mats will
be needed for overflow conditions, or how many nurses will be needed for a health clinic at Shelter X on
the next Tuesday. These types of decisions are very local and very practical. Usually they are made at
the program level on the basis of past experience, without a great deal of data-based analysis except
perhaps to look at agency records of services delivered, if they exist. Temporal variations over the week,
month, or season are also important for planners at this level, and will most likely be based on historic
agency data or personal experience.

A similar type of planning may occur at the city or county level as officials try to anticipate how many
shelter or transitional housing beds might be required to accommodate average and maximum demand,
and how many services of other types might be appropriate for shelter users. The simplest approach to
this is to ask what was used last year. Need for growth or change in the system's capacity could be
approached by examining local economic factors (e.g., plant closings, economic downturns), and

National Symposium on Homelessness Research 1-9

Demographics and Geography: Estimating Needs

possibly also by looking at service requests that could not be met anywhere in the system as an indicator
of unmet need. Care must be taken, however, to be sure that one does not count persons turned away
from one facility on one day who receive the requested services either from another provider on the same
day or any provider within a few days of the request.

More Complicated Planning Issues

Once planning advances to questions of the types of service that ought to be available, to planning a
comprehensive and accessible continuum of care, or to client length of stay and its relation to needs for
different types of services at different points during a stay, more detailed data are needed if planning
decisions are to be driven by facts. It will probably be important to be able to anticipate client
characteristics that call for different program structures and services.

For instance, knowing the proportion of households with children who will ask for homeless assistance,
in comparison to women or men by themselves, may help agencies or whole communities structure their
emergency and transitional shelter resources to accommodate these different types of households.
Likewise knowing that, historically, half the people asking for help have some type of immediate health
problem may let agencies or community planners prepare to treat those problems. Knowing how many
people using homeless assistance programs suffer from mental illness, chemical dependency, and other
debilitating conditions can indicate what the level of need for those services are in the population.
Finally, knowing how many people are released from psychiatric hospitalizations, detoxification
programs, jails or prisons without any reliable plans for housing can provide clues about the demands
these people will make on the emergency services system, and possibly also provide documentation to
support enhancing the capacities of mainstream systems to take responsibility for aftercare so as to
prevent homelessness among these vulnerable groups.

An important issue for planning is knowing how clients see their needs, and how their perceptions might
differ from the ways that agency staff see needs. Clients tend to focus on the end point (a job, an
apartment), while staff tend to focus on the steps that need to be taken before that endpoint can be
achieved (gaining skills, conquering addictions). Both are important. It may not always be easy for staff
and clients to reach a meeting of minds about what needs to be done today and tomorrow if the clients'
ultimate goals are to be reached. On the other hand, planners must not lose sight of the need for more
jobs, more housing, and more services that help people keep their jobs and housing. More case
management will not help people get jobs and housing if there are no jobs or housing available.

Another significant issue for planning is knowing whether the clients coming into homeless assistance
programs will be short-term or long-term users. This is especially important in shelter/ housing and
health programs, where the intake and other procedures that occur on the first day are often the most
costly and absorbing of staff time. Client flow is also important in planning caseworker load and types of
services to offer. If a program's clients or a whole city's homeless population are mostly short-term, a
greater proportion of resources will need to be dedicated to intake than if most of the clients are long-
term.

1-10 National Symposium on Homelessness Research

*
i

E
is

■0

(Q
V>

H
J
CO

;*>

« -

Cfl

J3 *Z

M e

T3
O

"Si w
.Sf a

2
_B

u-»

u. B

S-i

0> I— 1

•„3

£ »

£ 5

•

«>•

co
Ih
CU

'co
'u

-o

(U co

i- «

_>^

3
X

C CO

>-> a ^

x a

Ih U

E
O

CO
CO

NJ C

.3 <D
CO o

B I
O co
•*3 E

ca o

J3
H

J3
OX)

s
t o
"-is

(4-1

CO
O

CO
*Ih

O
CTJ

•o

E
ca

O
>

Ih
<V
eo

CCS

u-
O

.5 "ca 3
*- a co

* S X

5 E .2,

| • ©

a «, C
O w 4)

8 '> 2

.S Ih CJ

S (U ,

.2 w ^g

2 *
la -o

« a

>-> CU

Ih 1>

Cu co
CO w

l-l ^
cu co
X "O

c <u

B - ID

E
O

E
ca

CO
CO
CU

CO
CO

32
<u

E
O

■o

3
to

B ^ E

I s .a

■5 Cu >

E
o

<H«

'a
o

u.
X

ca
>

co
Ih
4)
X

•

res
Ih
U

CT3

"a
o

'S L °

<u ca u
1 = a

ja -t- 1 co
£ S3 h
U o. a,

Gh CU CO

*- -O Ih

E E O
(U CU ••_?>

• — +j ca
U cu S

> a
° S

u. ca

Cu CL,

-5
o

'cL

"ca _

Cu §
H co
cu M

ll a

t - ' CO

.9 E
co .2

C S H

2-8 2
H J 2

- f2 <u

<4H

CU
13

<+H

53
E

o
X
u_

« O ■£

cu M cu
a bo .

c E U

co" -a .s

T3 -B >

S o

■S 5

> E

Ih U

o cc

CO
CO

13
E

q3 TO Uc

a cu

Cl,

E
o
u

^ -O C4H

o o o

2 c rt

s»>

'■*— »

E CO >,

B ">

C ^ IU

>> «a i_

.a u d.

U js O

ca *3 b
U JB <

O 2 b0

"ca
o

J3
H

o
Q
<**

B
O
o

'S.
_o
13

o
ca

*lH

fc; co a — '

Cu >, .-. ih

a°.a § S
•« > • ^

. h "» cu

W So > 8

•s u a S
& -a a >>

•J c c S

5 (U p-h co

3
O

a
'>

_E
'>

♦2

'co

—

[E.

lo-

C
eg

Cu
U

co
Ih

a
u

Ih CO

-8 S

E 2

5 E

.a «

3 "3

« E

—

CD
>

O
60

^h Ih

ea 
O O
— co 60

a £>

ca «a

« CO 73

o
u

l-i o. .

Ih Cu Ih

•o
ca

U3
O

cu 3 «J

■S o ca
/*% i- 1 ■ 4 -'

O MM

cu 3 CU

•Sol?

X Ih r 1 *

O bO PL,

•

• •

CO
<D
Ct

0)
(0
CD

w
_g>

E
o

<o
o

E
>.

"co

c
o

Demographics and Geography: Estimating Needs

In addition, some services will not be appropriate or needed for short-term clients. One should not plan
to put every client through an assessment process that takes three weeks if the average length of stay is
two weeks, nor can one expect to produce major life changes in two weeks. What is being asked for is,
quite literally, emergency assistance. With respect to transitional programs, if the maximum length of
stay is two years and a program has a sequence of services that requires two years for its full effect, the
program will be less effective when the average length of stay is six months. Also, any program with
many short-term clients that has any plans for follow-up work or data collection with former clients will
quickly be overwhelmed by the growing number who need tracking; this issue is less severe if the
program has mostly long-term clients.

Finally, client flow data are important when planning solutions to homelessness. If the homeless
population of a community is small and stable (mostly long-term), investing in permanent supported
housing will probably be a more humane and cheaper solution than maintaining people in emergency
shelter. But if the same small population is largely short-term and turnover is great, finding solutions to
homelessness will entail helping a group of people that in one year may be three (New York City,
average length of stay=4 months), six (Philadelphia, average length of stay=2 months), or even more
times the number of people who are homeless at any given time (Burt, 1994; Culhane et al., 1994).

As an evaluator by trade, the author would feel remiss if she did not point out in this paper that one
critical piece of information important to planners is almost always missing, namely, information about
which programs and services are effective. People always ask this question, but very few agencies are
willing to spend the time and money to find out. So planners use all the information available to assess
needs, and then support programs that for the most part have not been proven to have a track record of
success (which does not mean they are failures, merely that we do not know which are the most effective,
and cost-effective, ways to spend homeless assistance dollars). This point will ve revisited at greater
length at the conclusion to this paper.

Methods for Collecting Information for Planning

Many methods exist to obtain information about the client characteristics and geographical location that
planners may use to estimate need for services (for extensive descriptions of these and other methods, see
Burt, 1992b). None of these is always right, or always better. Certain data needs may require specialized
techniques of data collection, but it is also true that many different techniques are capable of gathering
the basic types of information listed earlier in Table 2. Every data collection effort is a compromise
among data needs, the expense of getting relevant information, respondents' tolerance for talking to data
collectors, and the planner/researcher's abilities and resources for analysis and interpretation. This being
said, Table 3 details some commonly used methods of data collection, dividing the options into those
designed to obtain full counts through methods that do not rely on probability sampling, methods based
on probability sampling, tracking databases, and other approaches.

1-12 National Symposium on Homelessness Research

.E
■°>

z
o

as
O

o
z

z
z

« s

M H

J u

CO fa

H J
O
U

1/5

Q
O
X
H
fa

o
u

a
•a

—
a

E
o
U

— 4,

X *-

Xi JH

2 ©

Q t/5

O C*H

^ 03

fa ►,

<=> "2

8 35

E *-

_ a»

a "E,

3 O

tfl 4>

3 On

o
JS

■a
©

>. o

O TJ

Oil

re)
O

t/>

TJ
•—
O

r )

1—

-a

(!)

re)

•j-i

rej

(/I

—

o
c
<u

bO
03

<u
a,
oo

-O

O
o
u

4-C

—

■a
c
tu

-2 w

G. oo

E .a

+i s o

e "§ i-

o " •
•a c TJ

3 .2 -a

tu re) o

S 3 ^
3S- 3

Was

o
a,

re!

00 >~> „

1 s i

1 &s

, , to :^

01 ■ a

° S o
S § —

M g ^

S3 o S

'— "

C in ^

re)

i—

-i

C/l

J-i

res

■3 re!
O0 TD

2 3

0<3 C«

O w

pa S

r 13

m ja

o a
u 2

■ S C

.a -8

m C

o °

4- OT

c •-

o >,

■a X)

t) (LI

a Oh

W 2

o
a,

re)

60
O

—

w <

S c
" a

o
a.

c •-

o >,

•a xi

« -ii

<U <U

E t-

3 O

e o-

m 2

C rel

■r E

.s '-s

O D

. - (J

^ u

e 13

o >

E a

M a.

J2 -g

"^ s

g u

u E

oo -a

8
<U
toO
re)

(l)

re)

.2"

too

c/l

.2
>

CD
>

4-1

,— ^

—

JSij

re)

c/i

c/l

a
o

^-^

E
on

o
rel

"o
U

i-T

u

u-
o

c
u

oo
Ih
U

OJ
TJ

■! i

.2 '■§
o <u

C o

. .. CJ

oo c

-C tu

a 13
o >

E 2

1)
15

TJ
O

D-

re)

CD
TJ

re)
oo
(U

a
tu

too 3
t> 03
.2 E

^ -2

oo .5

Xi
>^ TJ

o 5

too O

03 S3

£ "S a

G u '-—

j- <-. Oh

5 fa §

•S o o
- a oo

|S3

> a .a
§1 -

° -« -E

D C^ >

S g §
o § S

U oo tU

-a

J2
03
Xi

o
a.

«5

•^

1—

(LI

03
TJ

>
tu

"•3

"X!

60
tu

'>
e

a
<

3 *

oo (J

-S Q

'I _r

•_E u

IE N

o tu
cl>

-^ ■-"

o f

° o

pq oi

4-1

'—

l—

'—

too e oo

.£ I "§

2 §1

c .2 w>

-age
S > i-

3 ° 2

-a
o

03
O

C/l

re!

t/i

C/l

(1)

^«

re)
00

oij

(1)

^—^

0/)

'^Z

C )

u.
E

E
o

. -

03
l-i

a
<
2

t~-

t/3

1 — 1

£
z
z

<c
-J

fa H
J U

CO a

< fa

as
o

fa
03
Q
O

B
H
fa

o
u

*o _

c/f
o

til

"3 W

«M

O oo 1

on
1)

^ ca

3 c

.2
3 00
ca ii

6 ft

ill

'a
s

o
U

6 ~

OO ca

1/5 u

J ft
5 a

0) co

£ 3

ft
CD

T3
ca

— . w
■e J}

2 ©
fa u

-a

'oo

s
<u
•a

3
O

a,
00

•—

O "3 *-*
_> cu B
00 "S ' .

3 i2

U E 3

x 2 "o

U 0=1 ft

(so

"O C

O JJ

5 a

Q (A

O (H

* -

' c s

3 «

E T3

_o
'C

ca
00

-a

-O
O
u
ft

"3 o

e ' C
3 <L>

'.£ ft

■3 o

-o
o

t-H

O O

3 ^
00 3

O '3
T3 ^

ft <D
. - o

la c
1 .2

60 C

C JD

'S «
W) >

2 3

3 &.

S ft

c 2

O ft

>-
ft

fa >,

*- s

CO A!

w 60

fa '"

ZZ *

co
bf)

" ®

CO 00

(U 1>

« "E,

a el)

a 9

13 is

W 01

.3 M

00 <

3 fa

■Ja

- .

a .s

co CD

co -e

60 Eh

.3 co

-o

,2 —

o "3
ca w

±3 co

►J >H

3
a.

■s ^

<L>

CD o

ooZ

v£. cg

33 ft

-a
u

GO O

>h '3

T3 ca

3 <u

00 g

O "3

CD
b

4-1

e
)-*

_ ft
s ~°

« e

1- 3

04-H
O
00

3 g

3 •«

3 3

0) O

-3

m4S

c -3

-3 33
00 ca

'u.

3
on

ca
J O

^ •■3

S O fa

co . JL.

3 00.2

73 W

33 U

Demographics and Geography: Estimating Needs

Full-Count and Other Non-Probability Methods

Included in Table 3 as its first row is a method that is probably the most widespread of all— analysis by
each agency of its own records of service delivery, to understand past experience as a guide to the future.
Some communities, as well as some whole states, have developed ways to aggregate these single-agency
experiences by having each agency report common data elements to a central office that compiles the
information for planning purposes. Even with such data, however, duplicate counting of individuals is
often a problem at every level, and for even the shortest time periods. Soup kitchens may be able to tell
you how many meals they served yesterday, but not how many people. Large shelters may be able to say
how many bed-nights were used during the past week or month, but not how many people were sheltered.
Even if individual agencies can produce unduplicated counts of people, once two or more agencies pool
their data into community-wide or statewide reporting, there usually is no way to tell what the
duplication might be across agencies either on the same day (e.g., Person A uses both a soup kitchen and
a shelter on Thursday) or on different days (e.g., Person B uses Shelter 1 during week 1 and shelter 2
during week 2).

Efforts to obtain simple counts of the homeless population usually occur on a single night and within a
relatively well-defined and not too large geographical area, and include searches of outdoor locations and
enumerations within shelters. Early and ongoing efforts to perform such counts occurred in Boston and
in Nashville (Emergency Shelter Commission, 1990; Lee, 1989). They obtained only the total number of
homeless people encountered, plus some minimal descriptive data such as gender and whether the person
was an adult or a child. The Office of Economic Opportunity in the Minnesota Department of Children,
Families and Learning has conducted a statewide variation of this type of count four times a year since
1985, learning for a specific night each quarter how many people in each reporting area are sheltered on
that night, along with whether they are men, women, or children, and whether the children are dependent
or alone. The fact that these surveys occur regularly (although Nashville has stopped doing theirs) gives
these jurisdictions a documented history and the ability to track trends, which can help with planning.

One variation on the simple count is to conduct a brief interview (usually about 10 minutes) with the
people enumerated, taking either a random sample or everyone. This approach has been used in many
places, including Pasadena, California (Colletti, 1993) and Colorado (State of Colorado, 1988). The data
collection is still largely limited to one night or to one 24-hour period, and produces a point-in-time
snapshot of the population. Because the interview is brief, relatively few issues related to service need
can be explored in depth, but more information can be obtained with this approach than is usual with the
simple count that relies heavily on observation.

The Kentucky Housing Corporation (1993) conducted another variation on the simple count. It used a
brief interview as did Pasadena and Colorado, but made several methodological changes that might be of
great interest to planners in other areas with relatively sparse populations and few homeless-specific
services. This study greatly expanded the types of agencies through which contact was made with
homeless people, including many mainstream agencies that homeless people might approach for
assistance. These included health and mental health centers, jails, libraries, community action agencies,
food pantries, agencies handling FEMA/EFSP funds, welfare offices, and generic social service agencies,
among others. Contact with each individual approaching an agency began with a two-question screener
that quickly identified the people who would need to complete the remaining 16 questions on the
interview. In addition, the time frame for data collection was extended from the usual one night to two
months. These changes were made to accommodate the scarcity of homeless-specific services and the
different patterns of service use found in the rural areas that make up most of Kentucky. Agency
contacts were supplemented by searches of outdoor locations, using homeless or formerly homeless
individuals as guides. This study also had to devise a method for unduplicating the various reports of
homeless people coming in from the different agencies over the two-month period, which it did by means

National Symposium on Homelessness Research 1-15

Demographics and Geography: Estimating Needs

of a unique identifier based on the last four digits of a social security number and the first four letters of
the person's last name. Kentucky will repeat this survey in 1999. A more elaborate version of this
methodology was pursued in rural Ohio (First, Rife & Toomey, 1994), using the same broad array of
contact agencies to identify homeless people, a six-month data collection period, and a much more
extensive interview.

Probability-Based Methods

The next set of methods described in Table 3 are those based on taking random samples and developing
estimates rather than full enumerations of homeless populations. Various things can be sampled at the
first stage, including city blocks or other geographic areas, abandoned buildings or conventional housing
units in very low-income neighborhoods, or homeless assistance and other service programs. Once at the
sampled location, individuals found there are sampled and interviewed. Block probability methods have
proved to be very expensive, and are mostly not used any more since it has become clear that different
versions of service-based methods will achieve as much or more coverage of the homeless population in
many instances. There are exceptions, of course, for specific subpopulations among the homeless who
rarely or never use services. But the way to assure coverage for these subpopulations will most likely
involve visits to locations they are known to frequent rather than on random selection of blocks. The
data collection sites may be randomly selected (for instance, by selecting abandoned buildings from a
city's list of tax-foreclosed properties), or they may be purposively selected as in DC*MADS' use of
street "encampments" and the Course of Homelessness study's use of known outdoor locations in
downtown Los Angeles and the parking and camping areas in Los Angeles' west side beach communities
where many homeless people who did not use services could be found.

Probability-based methods take more sophistication to use than simple one-night sweeps of shelters and
city streets, but their advantage is that they usually can provide more accurate estimates of the non-
sheltered parts of the homeless population. And, because sampling cuts down the number of individuals
one must speak with, more extensive data may be collected through interviews for the same resource
commitment as would be used to try to find and/or speak with everyone. Much has been written about
the advantages of these methods, so no more will be said here, except to point out that service-based
random sampling could be done by local researchers for reasonable cost and could provide much useful
information.

Tracking Data Bases

Tracking databases (usually of shelters) have received a lot of attention recently, due in part to the many
articles that have appeared using the Philadelphia and New York City databases (see, e.g., Culhane et al.,
1994) and to the growing interest in ANCHoR and other tracking database software. A growing number
of other cities have similar types of tracking systems, including Boston, Detroit, Anchorage, Baltimore,
St. Paul/Ramsey County, Minnesota, Columbus/Franklin County, Ohio, Santa Monica and San Diego,
California, Ft. Worth, Texas, Denver, Colorado, the State of Rhode Island, and Maricopa County,
Arizona (including Phoenix). Burt (1994) summarizes data from some of these. Interest has been
growing among municipalities in developing systems that can unduplicate across programs and over
time, and there has been an effort to develop "canned" systems that still contain the flexibility to be
adapted to the needs of different communities. Systems developed in Denver and San Diego have been
adapted by some other localities, and the U.S. Department of Housing and Urban Development has
supported the development of the ANCHoR system by a group at the University of Pennsylvania and
PRWT, Inc. (For information about ANCHoR, visit its website at www.prwt.com/anchorl). Approaches
to actually getting the data into the community-wide system have varied, with some communities placing
linked computers in every service agency, others having service agencies send hard copy to a central
location for data entry, and some communities do both.

1-16 National Symposium on Homelessness Research

Demographics and Geography: Estimating Needs

Culhane and Kuhn (1998) make a strong case for the value of this type of data for administrative
purposes. They discuss the value to planners of obtaining knowledge of client flow, the distribution of
short and long stays, and analysis of client characteristics among people with significantly different
patterns of stay. These data would contribute to planners' ability to estimate the potential demand for
prevention and crisis services, and to informed decision making about where the system wants to put its
resources.

These systems have not been without their glitches and downsides, however. They are hard to get up and
running to the satisfaction of all users of the system. Some systems may be set up with an emphasis on
community-wide analysis of data but individual agencies do not get much feedback that is of immediate
help to them in serving clients. Other systems emphasize the control of individual agencies over their
own data, which makes it valuable to each agency, but are weaker on the shared use of data and the
production of systemwide statistics. Issues of privacy and data confidentiality are always present, but
can be solved with concerted effort. This is important because once they start using a tracking data base
system, service agencies quickly recognize the value to their clients of being able to share information
about the client with other agencies. But if the system has been set up with maximum privacy
protections, this sharing may be difficult to achieve in retrospect. Another disadvantage of current
systems is that few include any services other than shelters. Maricopa County, Arizona is an exception,
as it includes a large health care for the homeless site that serves many street homeless people and also
asks about the homed or homeless status of people using other agencies in the system such as Head Start
and community action agency programs.

A final issue that is beginning to arise in some communities with several years of experience with
working data bases has to do with getting paid. Agencies have come to realize that some of their budget
comes in the form of reimbursement for services given to clients, and that these services are being
registered in the data system. There are anecdotes that agencies have become possessive of their clients,
possibly up to the point of not referring them to other agencies for services because they want all the
"credit" for that client. Communities installing tracking data bases and intending to use them as one
element in funding decisions would do well to address these issues of ownership and sharing directly, so
that clients get the appropriate services from the appropriate providers.

Other Methods

The last two data collection methods included in Table 4 are unlikely to be conducted by local or state
planners, but the information from the original studies should be of great interest. These include national
(or more limited) telephone surveys of households using random digit dialing, and longitudinal studies of
homeless populations. The first method can be used to get estimates of lifetime and recent homeless
experiences of currently housed people, while the second shows us the patterns of entering and leaving
homelessness over extended periods of time.

The estimates produced by shelter tracking databases of the proportion of whole city populations that
have experienced homelessness, hovering around 3 percent of the population over a three-year period, are
supported by results from a completely different source-household telephone surveys using random digit
dialing conducted by Link and his team. Their results are that about 3 percent of American adults (7 to 8
million people) experienced literal homelessness within the past five years (Link, Susser et al., 1994;
Link, Phelan et al., 1994).

Obviously, most of the homeless episodes tallied by the shelter tracking and the household survey data
did not last a very long time, or the one-day homeless population would be much higher than the 500,000
to 600,000 commonly thought to be a reasonable estimate for a 24-hour period. The new results have

National Symposium on Homelessness Research 1-17

Demographics and Geography: Estimating Needs

made both researchers and policy makers think again about what might be the best approach to serving
homeless people, and to consider what services might be relevant for someone who just needs a little
help to leave homelessness or for whom appropriate interventions might prevent homelessness, as well as
for someone who needs a lot of help.

Longitudinal studies of homeless cohorts became available in the 1990s for the first time. Several
research projects (in Minneapolis, Minnesota, Los Angeles and Oakland, California, and New York City)
followed a sample of homeless people over extended periods of time. These efforts (see Koegel &
Burnam, 1991; Koegel, Burnam & Morton, 1996; Piliavin, Sosin & Westerfelt, 1993; Robertson,
Zlotnick & Westerfelt, 1997, Schinn, 1997) reveal in great detail the complexity of homeless careers.
While some people may have only one homeless episode, during which they are "on the streets" for the
entire time, many people who are homeless at the time a sample is taken have moved in and out of
housing frequently, depending on their available funds and other supports.

The results of longitudinal research studies help us understand many things about homeless careers. On
one hand, they help us to see how many people experience single short spells of homelessness and are
able to leave on their own and never return. These people may never draw much attention from service
providers and planners because they do not draw heavily on service resources. Nevertheless, their
experiences can help us understand the circumstances that allow people to leave homelessness and stay
housed, and may also be important when planning prevention efforts.

On the other hand, these longitudinal studies help us to see the difficulties encountered by another set of
people who find it very hard to leave homelessness for good, and what it will take to truly end this type
of homeless career. Longitudinal studies have documented some of the near-term causes of homeless
episodes, and shown just how fragile is the hold some people have on stable housing. Planners should be
aware of these results as they think through what continuum of services they want to create in their
communities.

What Works?

Without knowing what works, planners with the best information in the world about the service needs of
homeless people will not be able to make the best decisions about which programs are the best
investment of local resources. Information about program performance and impact is relatively scarce in
the homeless services arena (which does not make homeless assistance services any different from most
other service arenas). Further, the information that we do have is skewed to particular types of programs
for particular segments of the homeless population. For the most part, we have the best information
about programs for people with mental illness and substance abuse problems and minimal information
about the effectiveness of services for anyone else, including families. Other papers in this symposium
go into much greater depth on issues of service effectiveness than there is space for here, but some
information about "what works" is essential here because it is so critical for decision makers to know,
and so rarely available, that it would be inappropriate for anyone to think they had all necessary
information just because they were able to describe their homeless population.

We know a good deal about how to serve homeless people with mental illness, drug abuse, or alcoholism
because several provisions of the Stewart B. McKinney Homeless Assistance Act of 1987 directed
federal government agencies to sponsor relevant service research projects. Portions of the Act authorized
funding to identify effective models of care that could maintain these most difficult-to-help long-term
homeless people in stable housing situations. The evaluation research was funded through the National
Institute of Mental Health and the National Institute on Alcohol Abuse and Alcoholism (Fosburg et al.,
1996; Morrissey et al., 1996; National Resource Center on Homelessness and Mental Illness, 1992;
Randolph et al., 1996; Shern et al., 1997; Sosin et al., 1994; Tessler and Dennis, 1989).

1-18 National Symposium on Homelessness Research

Demographics and Geography: Estimating Needs

The first, most remarkable thing we know is that the programs do work. Many of them have been able to
retain around 80 percent of the previously homeless people they serve in decent, stable housing
arrangements. We also know that without services attached, they do not work. The critical services
needed are: negotiating with landlords and neighbors, handling situations of decompensation or slipping
off the wagon, assuring that the rent is paid and the housing is kept clean, and supplying tangible goods
when necessary such as furniture, transportation, and food. These critical services are not readily
available from other agencies in the community, nor are they the responsibility of any other agency.
Therefore, they tend to be absent if federal funds do not cover them. Local decision makers would do
well to consider supporting these services with local funds if they want to create maximally effective
residential programs for their hardest-to-serve chronically homeless population.

Further, we know that without services, not only do the previously homeless people with serious
disabilities lose their own current housing, but they lose it in a way-by antagonizing landlords and
neighbors-that the housing unit itself is likely to stay lost and unavailable for other homeless persons.
Thus the program wastes the energy and resources already invested in finding and arranging the housing,
and has to start over with a bad track record. This is wasteful for all concerned, and does little to build
community good will toward homeless people with severe disabilities. Local planners may want to
assess the wisdom of spending funds for housing but not including the supportive services that make
housing investments successful.

The limited amount of research available on service outcomes for homeless families (Rog and Gutman,
1997; Shinn, 1997; Wong, Culhane and Kuhn, 1997) indicates the efficacy of providing housing
subsidies as a means of stabilizing residential patterns among homeless families and suggests that
without such subsidies, these families' personal resources, skills and human capital are not adequate to
maintain themselves in housing and otherwise take care of family responsibilities. These are also the
families likely to be the least capable of finding employment at the level of self-sufficiency, and therefore
to be the hardest hit by welfare reform provisions limiting the time of welfare receipt. Loss of welfare
income may precipitate episodes of homelessness.

Implications

We have learned a great deal about homeless populations in the past decade and a half, and have learned
even more about how to learn about them. Many of the methods described in this paper can be adapted
for use at the local and state levels, where they could produce extremely valuable information for
planning purposes. Most of the methods, once beyond simple counts, can supply decision makers with a
great deal of data about the characteristics of homeless people using services in a community. These
characteristics extend far beyond the simple demographics described above, and include the presence of
various disabling conditions that can be used to design the specialized services most appropriate to the
local population.

More and more communities are coming to recognize the value of good data for rationalizing their
service programs for homeless people. When you go to a community that has installed a tracking data
base, for example, they are most likely to tell you that the data don't resolve all of their priorities or make
all of their decisions. But since they have had the data, they say, they no longer spend any time arguing
about the scope of the problem (which they used to do all the time), and can focus their efforts on
deciding what to do about it.

National Symposium on Homelessness Research 1-19

Demographics and Geography: Estimating Needs

The newest types of data, in particular the tracking data bases, have raised many important policy issues
that were semi-invisible before. We now know, or could know, the proportion of homeless spells that are
very short term and the characteristics of the people who have them. This information could help us
design appropriate emergency services, including some that would not require a person to become
literally homeless (i.e., to enter a shelter) just to access them. By the same token, we now know, or could
know, the proportion of homeless spells that are very long-term, the characteristics of the people who
have them, and the amount of system resources they absorb. This information could help us to decide
that there are better, and even cheaper, ways to help these people through stable, supported permanent
housing arrangements.

The episodic group among the homeless is the most interesting, because its picture is least developed.
Culhane, because his data source is shelter stays, calls people episodic when they go in and out of shelter
regularly. But perhaps they are not episodic in the sense that they go in and out of homelessness; they
could merely move to the streets and back again to shelter. Other types of data would be more capable of
exploring different patterns of episodic homelessness.

In addition, we should ask what we mean by "episodic," as the word could have a number of different
meanings. Longitudinal studies help us to understand what some of these meanings might be. People
whose incomes last them only three weeks out of every month could be in hotels or motels for those three
weeks, and in shelters or on the streets for the rest of the month. This is a pattern that combines both an
episodic element and a long-term element (they have been doing this for years). In shelter tracking data
bases using a 30-day exit criterion, all of these people would be counted a continuous stayers (they would
never be out of shelter for a period greater than 30 days), but this pattern may not be what we intuitively
mean when we speak of "long-term chronic". Knowledge of patterns of service use may stimulate a
community to ask itself what it is really trying to accomplish with its services, and perhaps to design
better ways to intervene in pursuit of those goals.

Finally, it bears mentioning that we are living in a time when major streams of income support for very
poor individuals and families are being eliminated outright (General Assistance at the state and local
levels) or limited and restricted to certain people, for certain time periods, and contingent upon certain
prescribed behaviors (Temporary Assistance to Needy Families, formerly Aid to Families with
Dependent Children; Food Stamps). Anecdotes about how well welfare reform is "working" are
balanced by anecdotes about individuals and families who have lost benefits and become homeless. It
will be important in the coming years to document the effects of the fraying safety net on the abilities of
people to remain housed or to leave homelessness once in that condition.

1-20 National Symposium on Homelessness Research

Demographics and Geography: Estimating Needs

References

Barrett, D. F., Anolik, I. & Abramson, F. H. (1992). The 1990 Census Shelter and Street Night
Enumeration. Bureau of the Census, Decennial Statistical Studies Division. Paper presented at the
American Statistical Association Annual Meetings, Boston, MA: August 10.

Bassuk, E. L., Buckner, J. C, Weinreb, L. F., Browne, A., Bassuk, S. S., Dawson, R. & Perloff, J. N.
(1997). Homelessness in Female-Headed Families: Childhood and Adult Risk and Protective Factors.
American Journal of Public Health, 87(2): 241-248.

Bray, R. M., Dennis, M. L. & Lambert, E. Y. (1993). Prevalence of Drug Use in the Washington, DC
Metropolitan Area Homeless and Transient Population: 1991, Rockville, MD: National Institute on
Drug Abuse, Division of Epidemiology and Prevention Research.

Burt, M. R. (1992a). Over the Edge: The Growth of Homelessness in the 1980s. New York, Russell
Sage Foundation.

Burt, M. R. (1992b). Practical Methods for Counting Homeless People: A Manual for State and Local
Jurisdictions. Washington, D.C.: Interagency Council on the Homeless and the Department of Housing
and Urban Development.

Burt, M. R. (1994). Comment on Dennis P. Culhane, Edmund F. Dejowski, Julie Ibanez, Elizabeth
Needham, and Irene Macchia's "Public Shelter Admission Rates in Philadelphia and New York City:
The Implications of Turnover for Sheltered Population Counts." Housing Policy Debate, 5(2): 141-152.

Burt, M. R. & Cohen, B. E. (1989). America's Homeless: Numbers, Characteristics, and the Programs
that Serve Them. Washington, DC: Urban Institute Press.

Burt, M. R., L. Y. Aron, D. D. Chaplin, and S. E. Cavanagh. (1993). The Homeless in the 1990
Decennial Census: Description of Persons Found in Emergency, Runaway Youth, and Battered Women's
Shelters, Visible in the Streets, and in Other Selected Group Quarters. Washington, DC: Urban Institute.

Caton, C. L. M., Shrout, P. E., Eagle, P. F., Opler, L. A., Felix, A., & Dominguez, B. (1994). Risk
Factors for Homelessness Among Schizophrenic Men: A Case-control Study. American Journal of
Public Health, 84: 265-270.

Colletti, Joseph. (1993). The City of Pasadena Homeless Count: September 23, 1992. San Gabriel
Valley, CA: Lutheran Social Services of Southern California.

Culhane D. & Kuhn R. (1998). Patterns and Determinants of Public Shelter Utilization Among
Homeless Adults in New York City and Philadelphia. Journal of Policy Analysis and Management,
77(1): 23-43.

Culhane, D. P., Dejowski, E. F., Ibanez, J., Needham, E., & Macchia, I. (1994). Public Shelter
Admission Rates in Philadelphia and New York City: The Implications of Turnover for Sheltered
Population Counts. Housing Policy Debate, 5: 107-140.

Culhane, D. P., Lee, C. M., & Wachter, S. M. (1996). Where the Homeless Come From: A Study of the
Prior Address Distribution of Families Admitted to Public Shelters in New York City and Philadelphia.
Housing Policy Debate, 7(2): 327-365.

National Symposium on Homelessness Research 1-21

Demographics and Geography: Estimating Needs

Emergency Shelter Commission. (1990). State of Homelessness in the City of Boston, Winter 1989-
1990. Boston: Author.

First, R. J., Rife, J. C, & Toomey, B. G. (1994). Homelessness in Rural Areas: Causes, Patterns, and
Trends. Social Work, 39(1): 97-108.

Fosburg, L. B., Locke, G. P., Peck, L. & Finkel, M. (1997). National Evaluation of the Shelter Plus
Care Program. Washington, DC: U. S. Department of Housing and Urban Development, October.

Herman, D. B., Susser, E. S., Struening, E. L. & Link, B. L. (1997). Adverse Childhood Experiences:
Are They Risk Factors for Adult Homelessness? American Journal of Public Health, 87(2): 249-255.

Kentucky Housing Corporation. (1993). Kentucky Homeless Survey Preliminary Findings. Lexington,
KY: Kentucky Housing Corporation.

Koegel, P. & Burnam, M. A. (1991). The Course of Homelessness Study: Aims and Designs. Paper
presented at the 1 19th Annual Meeting of the American Public Health Association, November 1991,
Atlanta, GA. Santa Monica, CA: RAND Corporation.

Koegel, P., Burnam, A., & Morton, S. C. (1996). Enumerating Homeless People: Alternative Strategies
and Their Consequences. Evaluation Review, 20: 378-403.

Koegel, P., Melamid, & Burnam, M. A. (1995). Childhood Risk Factors for Homelessness Among
Homeless Adults. American Journal of Public Health, 85(12): 1642-1649.

Kuhn, R. & Culhane, D. P. (1998). Applying Cluster Analysis to Test a Typology of Homelessness By
Pattern of Shelter Utilization: Results From the Analysis of Administrative Data. American Journal of
Community Psychology, 26(2): 207-232.

Lee, B. (1989). Stability and Change in an Urban Homeless Population. Demography, 26(2): 323-334.

Link, B. G., Susser, E., Stueve, A., Phelan, J., Moore, R. E., & Struening, E. (1994). Lifetime and Five-
Year Prevalence of Homelessness in the United States. American Journal of Public Health, 84: 1907-
1912.

Link, B., Phelan, J., Bresnahan, M., Stueve, A., Moore, R. & Susser, E. (1995). Lifetime and Five- Year
Prevalence of Homelessness in the United States: New Evidence on an Old Debate. American Journal of
Orthopsychiatry, 65(3): 347-354.

Mangine, S. J., Royse, D. & Wiehe, V. R. (1990). Homelessness Among Adults Raised As Foster
Children: A Survey of Drop-in Center Users. Psychological Reports, 67: 739-745.

Morrissey, J., Calloway, M., Johnsen, M. & Ullman, M. (1997). Service System Performance and
Integration: A Baseline Profile of the ACCESS Demonstration Sites. Psychiatric Services, 48(3): 374-
380.

National Resource Center on Homelessness and Mental Illness. (1992). Annotated Bibliography:
Developing Housing for Homeless Persons with Severe Mental Illnesses. Delmar, NY: Policy Research
Associates, Inc., March and September. (1 800 444-7415).

Piliavin, I., Sosin, M. & Westerfelt, A.H. (1993). The Duration of Homeless Careers: An Exploratory
Study. Social Service Review, 67: 576-598.

1 -22 National Symposium on Homelessness Research

Demographics and Geography: Estimating Needs

Randolph, F., Blasinsky, M., Leginski, W., Parker, L. B., Goldman, H. H. (1997). Creating Integrated
Service Systems for Homeless Persons with Mental Illness: The ACCESS Program. Psychiatric Services

48{3): 369-373.

Ringwalt, C. L., Greene, J. M., Robertson, M. & McPheeters, M. (1998). The Prevalence of
Homelessness Among Adolescents in the United States. American Journal of Public Health, 88(9):
1325-1329.

Robertson, M. J., Zlotnick, C, & Westerfelt, A. (1997). Drug Use Disorders and Treatment Contact
Among Homeless Adults in Alameda County, California. American Journal of Public Health, 87 (2):
217-220.

Rog, D. J. & Gutman, M. (1997). The Homeless Families Program: A Summary of Key Findings. In S.
Isaacs & J. R. Knickman (Eds.), To Improve Health and Health Care, 1997: The Robert Wood Johnson
Anthology, San Francisco: Jossey-Bass Publishers, 209-231.

Rossi, P. H. (1994). Troubling Families: Family Homelessness in America. American Behavioral
Scientist, 37: 342-395.

Rossi, P. H., Fisher, G. A. & Willis, G. (1986). The Condition of the Homeless in Chicago. Amherst,
MA and Chicago: Social and Demographic Research Institute and the National Opinion Research Center.

Shern, D. L., Felton, C. J., Hough, R. L., Lehman, A. F., Goldfinger, S., Valencia, E., Dennis, D., Straw,
R., & Wood, P. A. (1997). Housing Outcomes for Homeless Adults with Mental Illness: Results from
the Second-Round Mckinney Program. Psychiatric Services, 48: 239-241.

Shinn, M. (1997). Family Homelessness: State or Trait? American Journal of Community Psychology,
25(6): 755-769.

Sosin, M. R., Yamaguchi, J., Bruni, M., Grossman, S., Leonelli, B., Reidy, M. & Schwingen, J. 1994.
Homelessness and Substance Abuse in Community Context: A Case Management and Supported Housing
Demonstration. Chicago: University of Chicago, School of Social Services Administration.

State of Colorado. (1988). Report of the Governor's Task Force on the Homeless. Denver, CO.

Susser, E. S., Lin, S. P., Conover, S. A. & Struening, E. L. (1991). Childhood Antecedents of
Homelessness in Psychiatric Patients. American Journal of Psychiatry, 148: 1026-1030.

Susser, E. S., Struening, E. L. & Conover, S. A. (1987). Childhood Experiences of Homeless Men.
American Journal of Psychiatry, 144: 1599-1601.

Tessler, R. C. & Dennis, D. L. (1989). A Synthesis of NIMH-funded Research Concerning Persons Who
Are Homeless and Mentally 111. Rockville, MD: National Institute of Mental Health, Division of
Education and Service Systems Liaison, Program for the Homeless Mentally 111.

Tourkin, S., & Hubble, D. (1997). National Survey of Homeless Assistance Providers and Clients: Data
Collection Methods. Suitland, MD: U. S. Department of Commerce, Bureau of the Census.

Vernez, G., Burnam, M. A., McGlynn, E. A., Trude, S. & Mittman, B. (1988). Review of California's
Program for the Homeless Mentally Disabled. Santa Monica, CA: The RAND Corporation.

National Symposium on Homelessness Research 1-23

Demographics and Geography: Estimating Needs

Weitzman, B. C, Knickman, J. R. & Shinn, M. (1992). Predictors of Shelter Use Among Low-Income
Families: Psychiatric History, Substance Abuse, and Victimization. American Journal of Public Health,
82: 1547-1550.

Wong, Y.-L. I., Culhane, D. P., & Kuhn, R. S. (1997). Predictors of Exit and Reentry Among Family
Shelter Users in New York City. Social Service Review, 71: 441-462.

Wong, Y-L. I. (1997). Patterns of Homelessness: A Review of Longitudinal Studies. Understanding
Homelessness: New Policy and Research Perspectives. Washington, DC: Fannie Mae Foundation.

Wood, D. L., Valdez, R. B., Hayashi, T., & Shen, A. (1990). Homeless and Housed Families in Los
Angeles: A Study Comparing Demographic, Economic, and Family Function Characteristics. American
Journal of Public Health, 80(9): 1049-1052.

1-24 National Symposium on Homelessness Research

Special Populations of Homeless Americans

Robert Rosenheck, M.D.

Ellen Bassuk, M.D.

Amy Salomon, Ph.D.

Abstract

Surveys conducted over the past two decades have demonstrated that homeless Americans are
exceptionally diverse and include representatives from all segments of society — the old and the young;
men and women; single people and families; city dwellers and rural residents; whites and people of
color; and able-bodied workers and people with serious health problems. Veterans, who are among the
most honored citizens in our society, appear in substantial numbers among the homeless, as do former
criminal offenders and illegal immigrants. Each of these groups experiences distinctive forms of
adversity resulting from both societal structures and personal vulnerabilities, and has unique service
delivery needs. All, however, experience extreme poverty, lack of housing, and a mixture of internally
impaired or externally inhibited functional capabilities. Attention to the distinctive characteristics of
subgroups of the homeless is important in facilitating service delivery and program planning, but may
also diffuse attention away from shared fundamental needs, and generate unproductive policy debate
about deserving vs. undeserving homeless people.

Lessons for Practitioners, Policy Makers, and Researchers

People who are homeless reflect the nation's diversity, and their special characteristics and needs

must be identified, respected, and addressed.

In addition to responding to basic needs for shelter, food, clothing and medical care, the unique needs

of each subgroup of homeless person should be sensitively addressed.

Systematic assessment is frequently required to identify the specific needs of each subgroup among

the homeless population.

Despite their diversity, almost all homeless people are extremely poor and lack decent affordable

housing and an adequate income. Regardless of their other difficulties, practitioners must address

their basic tangible needs for material resources.

Although it is essential that providers help facilitate homeless people's access to basic resources,

they also should advocate for increasing the overall pool of resources. Providers are often in a

position to be powerful advocates.

National Symposium on Homelessness Research 2-1

Special Populations of Homeless Americans

Introduction

Surveys conducted over the past two decades have demonstrated that homeless Americans are

exceptionally diverse and include representatives from all segments of society — the old and young; men

and women; single people and families; city dwellers and

rural residents; whites and people of color; and able-bodied

workers and people with serious health problems (Rossi,

1989; Burt, 1992; Robertson & Greenblatt, 1992). This

diversity illustrates how difficult it is to generalize about

the needs of homeless people, and how challenging it is to

assist them.

In contrast to the diversity, two characteristics are

remarkably consistent across subgroups of homeless

people: a lack of decent affordable housing and a lack of

adequate income. In view of the homogeneity of homeless

people with respect to these characteristics, and the

obvious relationship of poverty to homelessness, their

diversity is striking and deserving of review. Because

policy priorities are largely determined by the relative emphasis placed on the diverse rather than the

common characteristics of homeless people, it is important to consider the validity of each approach

before reviewing the literature on variations in subgroups.

Homeless People Reflect the Diversity
of Society

Age: Children, Adolescents, Elderly

Gender: Men and Women

Living Units: Single Individuals and

Families

Location: Urban vs. Rural

Racial or Ethnocultural Minorities

Health Status: Medial, Psychiatric,

Addictive Disorders, AIDS, Good

Health

Social Status: Veterans, Criminal

Offenders, Illegal Immigrants

Advantages of Evaluating Differences

Examining differences among subgroups of homeless people has some clear advantages. First, each
subgroup has unique service needs and identifying these needs is critical for program planning and
design. Detoxification programs, for example, are of little relevance for programs assisting homeless
children, and job counseling has limited value for people with severe addictions. Even psychosocial
characteristics, such as demoralization, lack of self-confidence or self-esteem, may have distinct roots for
people with different backgrounds.

Subgroup Focus: Advantages

Identify specific service needs

Guide staff selection
Specific skills

Common background facilitates
empathy and understanding

Guide interagency network

development

Second, identifying subgroup needs can guide agencies in
hiring staff with skills that are matched to their client's
needs. Programs serving people with mental illness need
access to clinicians with expertise in treating these
disorders, while programs serving latinos and other
minorities must hire linguistically and culturally competent
staff.

Finally, identifying group-specific service needs can provide

crucial information to guide development of responsive

interorganizational service networks. Homeless people

typically need assistance in multiple areas, often involving distinct agencies. Building alliances among

agencies with different missions, goals and values can be complex and time consuming, and it is

important that these efforts are appropriately targeted.

2-2

National Symposium on Homelessness Research

Special Populations of Homeless Americans

Subgroup Focus: Disadvantages

Distracts attention from common

needs for housing, income,

employment

Results in focus on personal failing

Reinforces concept of different levels

of deservingness

Drawbacks to Evaluating Differences

Focusing attention on subgroup differences also has

potential risks. While differenting subgroup needs may

assist some types of service planning and delivery,

attention may also be distracted from the basic needs

homeless people have for safe, decent housing and income

resources. Attending to differences may numb awareness

of the inevitability that in a market-oriented industrial

nation with a limited commitment of resources to safety net

services, some people inevitably fall into extreme poverty

and homelessness. Scholars and researchers consider

declining employment and public support of the poor, and reduced availability of low-cost housing to be

the primary reasons for the increase in homelessness since the late 1970s (Jencks, 1994; Rossi, 1989;

Burt 1992; Koegel, Burnam & Baumohl, 1996; O'Flaherty, 1995). Programs that target special needs

may blur awareness of the structural causes of homelessness and may lead policy makers to erroneously

explain homelessness as a result of personal or subgroup failings. Who is vulnerable in a particular

housing market should not be confused with why homelessness occurs at all. "Social poverty", although

it may appear differently in different subgroups, is often derived from long exposure to demoralizing

relationships and unequal opportunity (Tilley, 1998).

Populations that are prominently represented among the homeless are poor and lack access to low cost
housing. These subgroups may be better characterized as being systematically under-served by our
society's social safety net programs and opportunity structures rather than being uniquely burdened by
individual incapacities. Personal characteristics often found among homeless people may represent
markers of societal neglect and bias. Historical surveys of the changing faces of homelessness indicate
that the subgroups most vulnerable to losing their homes change with societal attitudes, safety net
programs, and medical technologies. The profile of homeless people reflects, in part, our social history.
For example, at the turn of the century the homeless population included amputees from the Civil War
and railroad accidents, the blind, and many people with syphilis (Bassuk & Franklin, 1992).

Commonalities: The Need For Adequate Housing And Income Support

Before we consider research on subgroup-specific needs of homeless people it is important to briefly
review the critical impact of policies and interventions that directly address housing and income needs of
all types of homeless people.

• During the Great Depression of the 1930s, large numbers of able bodied men were forced into
homelessness due to unemployment rates that approached 25 percent. With the outbreak of World
War II, however, the federal government provided employment for almost 18 million men and many
millions of women, and virtually eliminated homelessness from the American landscape.

• During the early 1950s, homelessness in urban skid rows was largely a problem of older alcoholic
men. With the advent of social security retirement and disability benefits poverty among the elderly
declined from 50 percent in 1955 to 11 percent in 1975 (Weir et al., 1988) and the risk of
homelessness for older Americans was vastly reduced (Rossi, 1989).

• A study comparing homeless and non-homeless people who used the same soup kitchens in Chicago
documented that the major difference between these two groups was that those who were not

National Symposium on Homelessness Research 2-3

Special Populations of Homeless Americans

homeless were receiving income through supplemental security income (SSI) (Sosin & Grossman,
1991).

• A prospective study of homeless mentally ill applicants for social security disability benefits found
that among those who received benefits, 50 percent exited from homelessness within three months of
the initial disability determination as compared to only 20 percent among those who were turned
down for benefits (Rosenheck, unpublished data).

• A study of housing vouchers and intensive case management for homeless people with chronic
mental illness found that vouchers, but not intensive case management, improved housing outcomes
and that neither intervention affected clinical outcomes (Hurlburt, Hough & Wood, 1996).

• A recent epidemiologic study of risk and protective factors for family homelessness indicated that
factors compromising a family's economic and social resources were associated with increased
vulnerability to homelessness. Specifically, being a primary tenant, receiving a housing subsidy or
cash assistance, and graduating from high school were protective against family homelessness
(Bassuk et al., 1997a).

An evaluation of a nine-city services-enriched housing program for homeless families (N=781) with
multiple problems, many of whom had been recurrently homeless, found that the vast majority of these
families were still in Section 8 housing at an 18-month follow-up. The authors concluded "that it may be
an investment in helping families to regain their stability and ultimately perhaps, their footing in the
workforce." (Rog et al., 1995b, p.513)

In each of these cases, in spite of the heterogeneity of the populations, income or employment
support substantially contributed to resolving the problem of homelessness. In the sections that
follow we consider empirical evidence on the background and needs of specific subgroups of
homeless people. We conclude by reconsidering the relative importance of homogeneity vs.
heterogeneity in policy development and service planning for homeless people.

Subgroups Of Homeless People

People who are homeless can be differentiated along six dimensions: (1) developmental phase of life
(age); (2) gender; (3) social unit (families vs. single individuals), (4) racial or ethnocultural groups; (5)
health status (psychiatric illness, substance abuse, HIV/AIDS, and the multiply diagnosed); and (6) social
status (veteran vs. citizen vs. criminal vs. illegal immigrant). In the sections that follow, we review
empirical research on the specific experiences and circumstances of each subgroup.

Developmentally Differentiated Groups: Children, Youth, and the Elderly

The loss of "home" — a place that nurtures development and provides safety across the lifespan — is
especially troubling to homeless children, youth, and elderly persons. Being without a home challenges
the unique developmental tasks of each age group. In addition, all these subgroups are particularly
vulnerable to the exigencies of shelter or street life because of their age, frailty, and dependence on
others.

2-4 National Symposium on Homelessness Research

Special Populations of Homeless Americans

Children

Prompted by increasing numbers of children living in poverty in the United States (Danzinger &
Danzinger, 1993), research in this areas has grown since the mid-1980s (McLoyd, 1998; Duncan &
Brooks-Gunn, 1997). In general, studies indicate that persistent rather than transient poverty is more
detrimental to children, and that children experiencing either type of poverty do less well on school
achievement, cognitive functioning, and socioemotional measures than children who have never been
poor (McLoyd, 1998).

Homeless children are among the poorest children nationally (Rossi, 1989; Wright, 1991). Researchers
have noted the similarities between homeless and poor housed children; homeless children look worse on
only some parameters (Ziesemer et al., 1994; Buckner & Bassuk, 1997; Bassuk et al., 1997; Masten et al.,
1993; Rubin et al., 1996). These findings suggest that homelessness may be only one stressor among
many in the lives of poor children and that cumulative effects of multiple stressors may be more
detrimental. In addition, one recent study of sheltered homeless and poor housed (never homeless)
children and families conducted in Worcester, Massachusetts [henceforth called the Worcester Family
Research Project (WFRP) (Bassuk et al., 1996)] found that the most powerful independent predictor of
emotional and behavioral problems in both homeless and housed poor children was their mother's level
of emotional distress (Buckner & Bassuk, 1997). Clearly, interventions that support the healthy
development of poor children must address the well-being of their mothers as well.

Homeless children are generally young children. According to a study of homeless families in nine
major American cities, the typical homeless family is comprised of a single mother, 30 years of age, with
two children under the age of five years (Rog et al., 1995). Research indicates that homeless children
have high rates of both acute and chronic health problems. They are more likely than their poor housed
counterparts to be hospitalized, to have delayed immunizations, and to have elevated blood lead levels
(Alperstein, Rappaport, & Flanigan, 1988; Parker et al., 1991; Rafferty & Shinn, 1991; Weinreb et al.,
1998). They also have high rates of developmental delays (Molnar & Rath, 1990; Bassuk & Rosenberg,
1990), and emotional and behavioral difficulties (Bassuk & Rosenberg; Molnar & Rath, 1990; Zima,
Wells & Freeman, 1994; Buckner & Bassuk, 1997). In the WFRP, the cognitive functioning of homeless
infants was comparable to their non-homeless peers. However, as children became more aware of their
environments, and the stresses of poverty and homelessness accumulated, mental health and behavioral
problems began to develop. Twenty-one percent of homeless preschoolers and almost 32 percent of
older homeless children (ages 9-17) had serious emotional problems. In addition, violence was endemic
in the lives of both homeless and housed poor families, with the majority of children either witnessing
violence or being directly victimized.

Homeless, more than poor housed children, face the formidable challenges associated with residential
instability and related family and school disruptions. Children who have moved three or more times are
more likely to have emotional and behavioral problems, be expelled from school, or be retained in the
same grade for more than one year (Simpson & Fowler, 1994 ; Wood et al., 1993; Baumohl, 1998). A
typical trajectory into homelessness is marked by multiple moves, with almost 90 percent of families
frequently doubling up with relatives and friends in overcrowded situations prior to becoming homeless.
The WFRP, found that homeless preschoolers had moved 3.1 times in the previous year, while the
average homeless school age child had moved 3.6 times (Bassuk et al., 1997b, Buckner & Bassuk, 1997).

In addition, many homeless children experienced other significant disruptions in their family and school
lives. In the WFRP, 9 percent of homeless infants and toddlers, 19 percent of preschoolers and 34
percent of school age children had been placed outside their homes. Not only is this rate significantly
higher than among their housed counterparts, but predictive modeling has shown that foster care is an

National Symposium on Homelessness Research 2-5

Special Populations of Homeless Americans

independent predictor of a myriad of adverse outcomes, including later homelessness (Bassuk et al.,
1997a). The WFRP also found that nearly three-quarters of homeless school-age children changed
schools at least once in a given year and nearly one-third repeated a grade. Consistency in schools or
daycare arrangements is associated with academic competence and later achievement (Baumohl, 1998).

Several researchers have looked at the adverse effects of shelter on children's development. While often
qualitative in nature, these studies generally underscore the importance of quiet, private space, the
potential negative impact of congregate living on parenting and the mother/child relationship, and the
negative impact of homelessness and shelter life on self esteem (Boxill & Beaty, 1990, also see section
on families); Hausman & Hammen, 1993).

Children spending time during their developmental years without the safety and stability of a permanent
home are at risk for various negative outcomes. Whether they are victims or witnesses to violence, have
learning difficulties or struggle with asthma or other health conditions, these children need to gain access
to developmentally appropriate services. In addition, permanent housing and adequate incomes for their
families are critical. An integrated approach toward designing a comprehensive system of care that
serves the well-being of the whole family is crucial.

Youth

Consolidation of one's identity, separation from one's parents and preparation for independence are key
developmental tasks of adolescence and critical for becoming a well-functioning adult in our society.
Most adolescents prepare for this transition to adulthood in their homes and schools. However, a
growing segment of young people leave their families prematurely, joining the ranks of homeless and
runaway youth (Powers & Jaklitsch, 1993). Whether by choice or forced to leave, these adolescents are
generally ill-equipped for independent living and many become easy prey for predators on the streets.

Despite increasing numbers of homeless youth and their growing proportion among the overall homeless
population (US Conference of Mayors, 1987), this subgroup was considered among the most
understudied and undeserved until relatively recently (Institute of Medicine, 1988; Farrow et al., 1991).
Although empirical studies have been methodologically limited, the growing literature suggests that
homeless youth are a special population that require innovative programmatic and policy solutions
(Robertson, 1991).

Pathways onto the streets are multiple and complex and include: 1) strained family relationships,
including family conflict, communication problems, abuse and neglect, and parental substance abuse and
mental health problems; 2) economic crisis and family dissolution; and 3) instability of residential
placements like foster care, psychiatric hospitalization, juvenile detention, and residential schools.
(Robertson, 1991; Camino & Epley, 1998). While terms and definitions vary, the essential distinction
between homeless and runaway youth appears to rest on assumptions about choice in leaving home,
access to the home of origin or an alternative home, and time away from home. Distinctions such as
these can be problematic because of presumptions about motives and options. Most definitions of
homeless youth refer to unaccompanied young people under age 18; the legal status of minor
distinguishes them in terms of access to services, employment, housing, and many other resources
(Robertson, 1991).

To survive, many homeless youth resort to drug trafficking, prostitution, and other forms of criminal
activity (Janus, McCormack, Burgess & Harman, 1987). Homeless youth are at risk for health and
mental health problems, including substance abuse (Robertson, 1989; Windle, 1989; Yates, MacKenzie,

2-6 National Symposium on Homelessness Research

Special Populations of Homeless Americans

Pennbridge & Cohen, 1988), HIV/ AIDS (Pennbridge, Yates, David & Mackenzie, 1990; Robertson,
1991; Rotheram-Borus, Koopman, & Ehrhardt, 1991), pregnancy (AMA, 1989; Edelman & Mihaly,
1989), and suicidal behaviors (Shaffer & Caton, 1984; Yates et al., 1988). Their high rates of exposure
to various forms of violence, both as witnesses and victims, increases the likelihood of developing post-
traumatic stress disorder and depression (Kipke et al., 1997). Many homeless youth have high rates of
mental health, alcohol and drug problems often in combination (Miller et al., 1980; National Network,
1985). Special needs groups within the population include: pregnant teens and young mothers,
physically and developmentally disabled youth, sexually exploited youth, gays and lesbians, and youth
with serious mental health, alcohol and drug problems (Robertson, Koegel, & Ferguson, 1990).

Limited shelter placements, fear of providers and shelters, and distrust of highly structured, rule-bound
programs, present unique challenges to service delivery. Streetlife makes it particularly difficult for
youth to access health and mental health services as well as educational programs (Powers & Jaklitsch,
1993). In addition, the multiple problems of homeless youth often bring them into contact with
unintegrated health, education, mental health, and law enforcement services. Rarely do these agencies
respond to the psychosocial and developmental needs of the whole person (Lindsey, Jarvis, Kurtz &
Nackerud, 1998). Homeless youth would benefit from programs that meet their immediate and basic
needs first, and then help them to address other aspects of their lives; both approaches should minimize
institutional demands and offer a broad range of services (Hughes, 1998). Also specially designed
programs that include street outreach, job training and employment, education, transitional housing,
youth staffing and mentors, and health care services have been described as especially important
(Camino & Epley, 1998).

Elderly Homeless

Although the proportion of older persons in the total homeless population has declined in recent years,
the numbers of homeless elders, age fifty and older, have grown (Susser, Moore & Link, 1993; Cohen et
al., 1997). While still a relatively small subpopulation, their numbers are likely to escalate as
homelessness continues unabated, increasing numbers of babyboomers reach older adulthood, and the
demand for affordable housing continues to outstrip supply (Cohen et al., 1997; Gilderbloom & Mullins,
1995).

Elderly homeless persons are of special concern because of their vulnerability to victimization both in
shelters and on the streets, their frailty due to poor mental and physical health, and the reluctance of
traditional senior service systems to incorporate them into ongoing programs (Ladner, 1992).
Homelessness uniquely challenges elderly persons. Not only does their vulnerability make meeting basic
human needs for food, shelter, and safety more problematic, but it interferes with resolving the later
developmental tasks of the lifecycle: the opportunity to reflect on one's life, consolidate personal
integrity, and experience completeness rather than despair (Erickson, 1963, 1986; Martin, 1990).

The research on homeless elders remains limited (Crane, 1994). With the declining age of the homeless
population, studies have primarily addressed the needs of younger individuals and families. Earlier
research that contained samples of older men among the single adult population focused on alcoholism or
"skid row" lifestyles rather than their age or life-cycle challenges. In addition, declining rates of poverty
among the elderly and a federally mandated system of targeted benefits and programs for older
Americans, coupled with the stigmatization of this subgroup, has made the elderly of limited concern to
policy makers.

Where studies exist, the age limit used for definition of elderly homeless people varies, from 50 to 65
years (Hudson et al., 1990; Kutza & Keigher, 1991; Cohen et al., 1988). Regardless of chronological

National Symposium on Homelessness Research 2-7

Special Populations of Homeless Americans

age, due to the harsh living conditions and the resulting magnification of acute and chronic physical
ailments, the elderly homeless appear older than individuals of the same age living in housing (Tully &
Jacobson, 1994). Depending on study samples, the proportion of men and women in the elderly
homeless population differ widely. Women are estimated to comprise 20 percent of the older homeless
population nationally, with numbers ranging from 8-33 percent, but make up a larger proportion of older
homeless individuals who use services (Cohen et al., 1997; Burt, 1992; Douglass, 1988; Ladner, 1992;
Roth Toomy & First, 1992; Kutza & Kreigher, 1991). Older homeless women's levels of alcoholism,
drug abuse and criminality are low compared to homeless men and younger women, while levels of
serious mental illness appear higher than among men and younger women (Cohen et al., 1997; Fisher,
1991; Wright & Weber, 1987; Crystal, 1984).

Factors that have been identified as contributing to the presence of elderly persons among the homeless
include deinstitutionalization (Boondas, 1985), poverty, especially among elderly women (Kutza &
Keigher, 1991), and the lack of affordable housing (Boondas, 1985; Kutza & Keigher, 1991; Tully,
1994). Limited access to affordable housing and supportive services is especially problematic for
minority elders (Bell et al., 1976; Bowling, 1991; Heuman, 1984; Tully, 1994). While elderly homeless
are generally thought to have more consistent income from pensions or social security than younger
homeless individuals, poor older women who have never worked, individuals with very limited benefits,
and elders whose meager incomes have been exploited by others, are still too poor to support themselves
in stable housing. In addition, based on information from service providers, many elderly become
homeless for the first time after the death of a spouse, child, or friend who had served as their caretaker
or provided financial support (Rafferty, 1986).

Older homeless adults experience various health and mental health problems, are more likely targets for
victimization and consequent injury, and lack networks of relatives or friends that could provide
emotional or material support (Hudson et al., 1990). One early report indicated that more than 50 percent
of homeless individuals over age 50 suffered from chronic mental illness (U.S. House of Representatives,
1984); other studies indicate that these individuals suffer from cognitive impairments, degenerative
mental diseases, and other psychiatric problems (Doolin, 1986; Kutza & Keigher, 1991). Complications
of aging may increase the stress of homelessness; for example, the decline in hearing and vision that
accompanies old age may create a general lack of trust and heightened anxiety since older homeless
people need to maintain vigilance to survive (Hudson et al., 1990). In addition, since older shelter users
are more likely to be crime victims than non-users (Keigher et al., 1987), some elders choose to remain
on the streets rather than use shelters. (Cohen & Sullivan, 1990)

Elder homeless need a complex and coordinated system of care that includes: specialized outreach, help
in meeting basic needs and sometimes routine activities of daily living, 24-hour crisis assistance, health
and mental health care, transportation services, assistance with the development of social relationships
and social ties, and a range of housing options with easy access to services. Studies indicate that some
elders do not trust service providers and fear limitations to their independence and the possibility of
institutionalization (O'Connell, 1990; Kutza & Keigher, 1991, Tully & Jacobson, 1994). For homeless
elders in hospitals, drug treatment programs or nursing homes, policies must ensure that they are
discharged only when adequate residential services are secured and that they are never discharged to
shelters or the street. In addition, cost reimbursement policies should not encourage premature discharge
or discharge without housing in place (Ladner, 1992).

2-8 National Symposium on Homelessness Research

Special Populations of Homeless Americans

Gender Issues

Since the mid-1980's, many more women have become homeless with the ratio of men to women
approaching 3:2. Women now comprise more than one-fifth of the overall homeless population (Burt &
Cohen, 1989, Rossi, 1990; US Conference of Mayors, 1991). The rapidly growing numbers of homeless
mothers (i.e., families with children in tow) and homeless women alone ("singles") account for these
numbers. Although the majority of "single" women have children, they reside in shelters without them.
In contrast only an estimated 40 percent of single men are fathers who are less likely to have been
married and are not active caretakers (Burt & Cohen, 1989; Calsyn & Morse, 1990). Burt & Cohen
concluded that "women bring their gender responsibilities into the homeless situation" (p. 521). As a
result, many authors have called for programming to meet their unique needs (Stoner, 1983; Bachrach,
1987; Merves, 1992).

In part, the transformation of homelessness by women reflects the feminization of poverty. Many
extremely poor women have limited earning power, job skills, and education and are overwhelmed by
childcare responsibilities. If they are raising children alone, these burdens are compounded. Female-
headed families are generally poorer than two-parent families because of the presence of a single income
and the cost of child care. Despite these facts, poor women do not have a realistic place in the current
labor market, which is designed to support nuclear families with male breadwinners. For example, the
gap between women's and men's income remains wide, and occupational and gender-related
discrimination is rampant. Women earn less over their lifetime than men, and the economic burden of
divorce often falls on their shoulders. Service sector jobs do not pay a livable wage or provide essential
benefits and TANF benefits, which will be cut as a result of the passage of the 1996 welfare reform
legislation, do not help women climb out of poverty (Merves, 1992; Bassuk, 1995; Buckner & Bassuk, in
press).

For women with limited education and job skills the picture is even bleaker. Improved technology
coupled with job competition from third world countries have led to reduced wages and higher
unemployment for these women. The availability of fewer jobs paying decent wages has particularly
affected the standard of living of young adults and minority group members (Buckner & Bassuk, in
press). Many homeless mothers have worked sporadically at low-paying service jobs such as sales
clerks, waitresses, cashiers, and babysitters, but generally not in the year before becoming homeless.
Even if a woman were working full-time and was able to arrange free child-care, her housing expenses
are likely to comprise an inordinate proportion of her income — far more than the 30 percent allotment
that is considered feasible; women comprise a disproportionate percentage of households who are "cost-
burdened" (Merves, 1992).

Various researchers have demonstrated that motherhood (in particular, pregnancy and the recent birth of
a baby), especially when parenting alone, may jeopardize a woman's ability to maintain her home
(Knickman & Weitzman, 1989; Hausman & Hammen, 1993). Women must juggle many roles — worker,
homemaker, and mother — often without adequate resources and social support. Raising children is a
financial burden and without government-sponsored childcare and enforceable child support laws, it
further constrains a mother's already limited job possibilities and earning power. Poor women who
manage to work are often on the edge of a precipice: a missed paycheck, medical emergency, unreliable
childcare, or other complication, may lead to job loss, eviction, and homelessness.

Although eviction and housing-related problems are a common precipitant of homelessness, domestic
violence is also a major factor. The risk of victimization is heightened in neighborhoods plagued by
extreme poverty, in situations where women are alone and lack protection, and in relationships with men

National Symposium on Homelessness Research 2-9

Special Populations of Homeless Americans

who suffer addictions (Bassuk & Rosenberg, 1988). Once on the streets, homeless women, especially the
"singles," are constantly vulnerable "to crime, street hazards and the elements" (Merves, 1992, p. 230).
A vast majority of single women who have been on the streets for longer than 6 months are likely to have
been assaulted and/or raped. As described in the section on homeless families, interpersonal violence is
also rampant in the lives of poor women and must be addressed in program planning.

Not surprisingly, many homeless people have various personal difficulties as well. Both single women
and men are far more likely to have histories of mental disorders, hospitalization, and suicide attempts
than women with children in tow (Hagen & Ivanoff, 1988; Burt & Cohen, 1989). As a result, many
single women have had their children placed in foster care or other out-of-home placements. With regard
to substance use disorders, single men have double the rate of single women who have double the rate of
mothers with children. It is also more likely that men are on the streets because of substance use
problems and involvement with the criminal justice system. Calsyen & Morse (1990) described that men
as compared to women tend to be on the streets longer, suffer a poorer quality of life, and receive less
housing and income assistance. They also found a "service gender gap" and speculated that "homeless
men are at the bottom of the hierarchy (of deservingness), in part, because of their greater abuse of
alcohol and drugs, and their criminal difficulties (Calsyn & Morse, 1990, p. 607). Culhane & Kuhn
(1998) also reported that an estimated one half of homeless men in comparison to one third of women
will be readmitted to the shelter system within two years.

In sum, although pathways into homelessness may be different for homeless men and women, each has
unique service needs that require innovative programming. "Homeless women suffer disproportionately
from every catastrophe specific to their gender and race. The problems they experience mirror those of
low-income women and are further compounded for women of color. These problems obstruct all
women, but not with the same intensity and frequency. Homelessness specifically demonstrates how
gender-related inequalities in large measure shape women's experiences." (Bassuk, p. 238). Although
pathways into homelessness are somewhat different for homeless men, they too suffer inordinately and
require comprehensive programming to address their complex service needs.

Social Units: Homeless Families

Family homelessness is a relatively new American social problem. Not since the Great Depression have
significant numbers of families and children been on the streets. Beginning in the early 1980's, families
with young children in tow have become one of the fastest growing segments of the homeless population
and now comprise approximately 36 percent of the overall numbers (U.S. Conference of Mayors, 1997).

The rapidly increasing gap between the incomes of rich and poor in America has jeopardized the stability
of large numbers of families. With limited education, job skills, child support and child care, their only
options for survival are low wage jobs or public assistance, neither of which provide sufficient resources
to keep a family stably housed. Often employed at minimum wage jobs, these families tend to pay an
inordinate percentage of their income on housing, thus increasing the pool of families at risk for losing
their homes (Buckner & Bassuk, in press).

Homelessness is a devastating experience. Losing one's home is a metaphor for disconnection from
family, friends, and community. Not only have homeless people lost their dwelling, but they have also
lost safety, privacy, control, and domestic comfort (Somerville, 1992). Homelessness disrupts every
aspect of family life, damaging the physical and emotional health of parents and children and sometimes
threatening the intactness of the family unit. For example, many family shelters exclude men and
adolescent boys. To avoid the stress of homelessness, some parents voluntarily place their children with

2-10 National Symposium on Homelessness Research

Special Populations of Homeless Americans

family, friends or even in foster care. Others lose their children to the foster care system just because
they are homeless (Shinn & Weitzman, 1996).

Goodman et al. (1991) have argued that homelessness is psychologically traumatic; it is a life event that
is "extraordinary, overwhelming and personally uncontrollable" (p. 1219). The stresses of living in
shelters are devastating for most people, but especially for women with young children. Although some
shelters involve residents in governance, overcrowding, curfews and other rules, as well as "public
parenting" tend to diminish any real sense of autonomy or personal control. Families have little privacy
and generally live in cramped quarters, sometimes with the entire family sleeping in one bed. In accord
with some shelters' policies, parents must relinquish responsibility for setting rules for their own
children. Severely stressed by the loss of a home, these mothers are often less able to protect and support
their children under these circumstances. Boxill and Beatty (1990) have described how the mother-child
relationship tends to unravel, in part because of the necessity of mothering publicly, and sets up a cycle
that is harmful to both. In an attempt to cope, it is not unusual for older children to assume the role of
parent — trying to nuture and protect their younger siblings and even their mothers from a dangerous,
uncertain and unreliable world (Bassuk & Gallagher, 1990).

Most research describing the needs of homeless families has been conducted in single cities, such as
Boston, New York, St. Louis, Minneapolis, Los Angeles, and Philadelphia. All have defined a family as
a pregnant mother or a parent with a child in tow. The samples include families residing in family
shelters. An important exception is the nine city assessment of the Robert Wood Johnson/HUD
Homeless Families Program; these families were residing in services enriched housing for longer than 4
months (Rog et al., 1995a, 1995b). Despite the difference in sampling frames, the findings are
remarkably similar to those previously reported.

When evaluating research on homeless families, it is important to be aware of certain limitations; the
samples generally exclude women residing in shelters for adult individuals, "singles"; the vast majority
of these women have children who are currently not residing with them. Smith & North (1994)
documented that homeless women have more personal vulnerabilities than homeless mothers such as
higher rates of psychiatric and substance use disorders (i.e., alcoholism), and some may have lost their
children as a result. In contrast, they describe homeless mothers as more socially vulnerable because of
their lack of employment and the stress of caring for dependent children. As Johnson and Krueger
(1989) concluded, homeless "singles" need more intensive psychosocial services, including mental health
and alcohol treatment, than homeless mothers with children in tow. (See section below on Gender.)

Who are homeless families and what are their needs? Most are headed by women in their late 20's with
approximately 2 children, the majority of whom are less than 6 years old. Their race/ethnicity reflect the
composition of the city in which they reside, with minority groups disproportionately represented. The
majority of mothers did not graduate from high school and were not currently working. However, most
had some work experience. Not surprisingly, homeless families were extremely poor, with incomes
significantly below the federal poverty level (Bassuk et al., 1996, Rog et al., 1995b, Shinn & Weitzman,
1996)

In the year before seeking shelter, many had become increasingly residentially unstable and had moved
3-5 times. Just before seeking shelter, most were doubled up in overcrowded apartments. When asked
why they lost their homes, Rog's sample most frequently mentioned eviction, inability to pay rent, and
domestic violence. Researchers agree that all families require decent affordable safe housing, adequate
income, education and job training, jobs that pay livable wages, and reliable high quality childcare.

National Symposium on Homelessness Research 2-1 1

Special Populations of Homeless Americans

In addition to these basic needs, other aspects of these family's lives must be addressed. Interpersonal
violence may well be the subtext of family homelessness. Abuse and assault seem to be the salient
feature of homeless mother's childhood and adult experiences. Women suffer its devastating medical
and emotional consequences for the rest of their lives. The Worcester Family Research Project (WFRP)
(Bassuk et al., 1996) documented that a staggering 92 percent of the homeless (N=220) experienced
severe physical and/or sexual abuse as measured by the Conflict Tactics Scale. More than 40 percent had
been sexually molested by the age of 12. As adults, almost 2/3 of the overall sample had been severely
physically assaulted by an intimate partner and 1/3 had a current or recent partner who was abusive.
More than one-fourth of homeless mothers reported having needed or received medical treatment because
of these attacks (Bassuk et al., 1996). Supporting these findings, Rog et al. (1995b) reported that almost
two-thirds of her sample of 743 women described one or more severe acts of violence by a current or
former intimate partner. Many women are fleeing violent relationships when they enter shelter. Others
are unable to leave these relationships without extensive support and as a result are unable to maintain
jobs. To be effective, policy makers must account for the pervasiveness of interpersonal violence in
program planning.

In addition to violence, homeless mothers suffer from other extreme stresses associated with poverty.
Similar to low-income women generally, they "experience more frequent, more threatening, and more
uncontrollable life events than does the general population (Belle 1990, p. 386). Unfortunately, they
often do not have adequate support to buffer these stresses. Compared to housed mothers, homeless
mothers had fewer non-professional network members, extremely small networks, more conflicted
relationships, and were less willing to seek support. In addition, the network members of the homeless
had fewer basic resources such as adequate housing and jobs, two meals a day and money to pay bills
(Goodman et al., 1991, Bassuk et al., 1996).

Given the high levels of stress and the pervasiveness of violence, it is not surprising that homeless
mother's have high lifetime rates of major depressive disorder (twice the rate of the general female
population), post traumatic stress disorder (PTSD) (three times compared to the general female
population), and substance use disorders compared to the general female population. Currently (within
the past 30 days), more than one-third had an Axis I diagnosis. In contrast to single adult homeless
individuals, homeless mothers do not suffer disproportionately from psychoses, such as schizophrenia.
Given the oppressive systemic and personal circumstances that engulf many homeless women, it is also
not surprising that they have astonishingly high rates of attempted suicide. In the WFRP, nearly one-
third of homeless mothers reported that they had made at least one suicide attempt before age 18 (Bassuk
et al., 1996). In Rog's (1995b) sample, more than one-quarter had attempted suicide, with 57 percent
reporting multiple attempts particularly by overdose.

Why do some very low-income families become homeless while others do not? Using univariate
statistics, researchers in New York City (Shinn, Knickman & Weitzman, 1991; Weitzman, Knickman,
Shinn, 1992), Los Angeles (Wood et al., 1990) and Boston (Bassuk & Rosenberg; Goodman 1991a,
1991b) have examined variables, such as social support, violence, and mental health, which may account
for a family's increased risk of becoming homeless. The results have been inconsistent across these
domains. Discrepancies may be due to differences in the timing of assessments, the type of comparison
group, and macro-level factors within the city (Buckner & Bassuk, in press).

A recent epidemiologic study (WFRP) investigated factors that might be protective against
family homelessness. Using multivariate modeling, protective factors included housing
subsidies, TANF, graduating from high school, having more people in one's social network and
having fewer conflicted relationships. Factors that reduced a family's economic and/or social

2-12 National Symposium on Homelessness Research

Special Populations of Homeless Americans

capital were also associated with homelessness. For example, mental hospitalization within the
last two years and frequent use of alcohol or heroin were risk factors although they were
uncommon among the sample (Bassuk et al., 1997).

In response to the growing crisis of family homelessness a safety net of family shelters and
transitional housing facilities have sprung up in the United States. Based on the latest HUD
shelter survey (1989) conducted in areas with populations greater than 25,000, the number of
family shelters had doubled between 1984 and 1988 — from 1900 to 5000 and are now the most
common shelter type. More recent estimates are unavailable, but with the continuing growth of
homeless families, it is likely that the number of family shelters has continued to climb,
"although probably at a lower rate of annual increase" (Weinreb & Rossi; p. 88, 1995). In
addition to housing assistance, most programs provide a broad array of programs including social
services (e.g., case management, counseling) and life skills training. Almost half of the shelters
provide follow-up to their residents (Weinreb & Rossi, 1995). In addition to shelters, most
communities also provide transitional or bridge housing for families who need more services and
support. Lengths of stay tend to be longer (6 months to 2 years) and services address both basic
and complex service needs. Rarely, permanent service enriched housing is also available, but
these programs tend to target families already living in subsidized housing who need additional
services to become self-supporting (Bassuk, 1990; Shlay, 1993). Although this continuum of
care is a good beginning, the data indicate that the emphasis in program planning should be on
permanent housing with services and supports available to families who chose them. (See
section on gender). Until more comprehensive programming is accomplished the well-being of
these families will continue to be compromised.

Racial and Ethnocultural Subgroups

Racial and ethnocultural minorities have long been at a serious disadvantage in the United States. In a
trenchant analysis of the ways in which intergroup patterns of social interaction become institutionalized,
Charles Tilley has described the process through which "durable inequality" emerges from exploitation
of categorically defined subgroups. Through this process persistent disadvantage becomes
institutionalized, appearing inevitable, intrinsic, and deserved — a basic fact of the way things are (Tilley,
1998). Perhaps the perniciousness of this processes and its ability to shape social perception has
contributed to our inattention of homelessness among minority groups — as if it were expectable and
therefore, in some sense, acceptable. Thus although minorities are at dramatically greater risk for
homelessness than other Americans, there has been virtually no specific study if minority pathways into
homelessness. Studies that address minority issues, have been, almost exclusively, sub-analyses of other,
more general surveys. For this reason alone, it is important that a report on subgroups of homeless
people not overlook the importance of race and ethnocultural group identity.

Blacks and latinos in America are far more likely than other Americans to be poor and therefore, more
likely to be homeless. In 1980, as the numbers of homeless began to grow, 30 percent of African
Americans lived in poverty and 23 percent of Hispanics, as compared to only 9 percent of non-Hispanic
whites (Baker, 1996). A government study released in 1998, based on a careful analysis that included
government and job-related benefits, found the gap between rich and poor, black and white, to be
increasing, even as the stock market soared (Passell, 1988).

National Symposium on Homelessness Research 2-13

Special Populations of Homeless Americans

Consistent with these income statistics, surveys conducted in the 1980s all showed that about half of all
homeless people were black, almost five times their representation in the general population (Hopper &
Milburn, 1996). Hispanics, paradoxically, were not over-represented among the homeless in most
localities and were under-represented in some (Baker, 1996). Therefore, we must consider the specific
circumstances of minority groups separately.

Homelessness Among African Americans

It is important to note, at the outset, that poverty alone does not account for the high risk of homelessness
among blacks. A systematic comparison of the proportion of blacks among the homeless and among
domiciled people living in poverty in US cities with populations of 100,000 or more, showed that poor
blacks living in urban settings were twice as likely to be homeless as poor whites in the same cities
(Rosenheck et al., 1996). Several factors may explain this additional difference: (1) wealth is likely to be
more important than income in the etiology of homelessness, (2) white flight and the departure of middle
class blacks to the suburbs have left pockets of concentrated poverty and reduced job opportunities in
urban areas, and (3) extreme segregation of housing by race and class seriously augments the adverse
effects of other types of economic disadvantage.

First, the gap in wealth between white and blacks is considerable. Oliver and Shapiro (1995) point out
that typical poverty statistics focus exclusively on income (e.g., average annual earnings, dividends and
government benefits) and exclude data on wealth - the totality of accumulated assets. While the income
gap between blacks and whites has narrowed considerably in recent years (black married couples earn 80
percent of white married couples, an annual difference of $6,500), the gap in wealth has not (black
married couples own only 27 percent as much as white married couples, a difference of $47,600).
Differences in wealth reflect differences in the long-term accumulation by assets in families. The major
asset of non-hispanic whites is their personal home, an asset whose value has increased markedly since
the end of World War II. Blacks however had little chance of owning a home in the immediate post-war
period; this partially explains why the wealth gap has yet to be narrowed.

Racial differences in wealth are important because, while income reflects resource availability in an
average week or month, wealth (savings) is what allows people to survive periods of adversity such as
job loss or recession. Thus, the much larger gap between blacks and whites in wealth can be expected to
result in far greater vulnerability among blacks to residential displacement during economic downturns
and lower levels of resource buffering capacity in their social networks.

Second, as documented by William Julius Wilson (Wilson, 1987, 1996), the loss of jobs in inner cities
has dramatically reduced employment opportunities for black men. This loss has been compounded as
upwardly mobile blacks have followed whites to more prosperous communities in the suburbs. Thus,
many inner city communities have lost their internal cultural strength.

Third, housing segregation has contributed substantially to the exceptionally high risk of homelessness
among blacks. As chronicled by Massey and Denton (1993) "redlining", the official government policy
during the 1930s that kept blacks from moving into white neighborhoods, and continuing patterns of de
facto discrimination in housing markets (Turner & Reed, 1990) have kept blacks and whites separate.
The separation is increasing and it seriously compounds problems associated with poverty and limited
employment opportunity (Massey & Denton, 1993). In a racially and socio-economically integrated
community, even though the disadvantaged suffer disproportionately especially during economic
downturns, neighborhood institutions and functioning are little affected because of the contributions of
better off residents. In contrast, in segregated communities, when poor people experience an economic

2-14 National Symposium on Homelessness Research

Special Populations of Homeless Americans

downturn or a reduction in public support, their communities suffer devastating losses of material
resources, infrastructure, and institutional capital. Although briefly sketched, factors operating at the
community level are likely to account substantially for the increased risk for homelessness among blacks
beyond income differences.

Several studies have noted systematic differences between homeless blacks and homeless whites —
differences that underline the relevance of these broad structural factors. Studies of two separate national
samples of homeless veterans (Leda & Rosenheck, 1995; Rosenheck et al., 1997) and a sample of several
thousand homeless people from 18 cities who are participating in the ACCESS demonstration program
(unpublished data from R Rosenheck & J Lam) have shown that homeless blacks are less likely to have
severe mental illnesses than whites, and have more social supports and stronger employment histories.
These strikingly consistent findings suggest that while disabling mental illness and social isolation are
major factors in the genesis of homelessness among whites, blacks are also affected by the historical
legacy of discrimination (e.g., in their lack of accumulated assets) and current urban dynamics which
push them over the edge into homelessness. In addition, an outcome study that compared black and
white veterans found that while admission to residential treatment in addition to case management had
little impact on outcomes among whites, black veterans had substantially better outcomes when they
were admitted to residential treatment programs (Rosenheck et al., 1997). Although not conclusive, these
data suggest that depletion of community social and economic resources may require additional
interventions at both the community and individual levels.

We have presented these issues at length for two reasons. First, they suggest that interventions seeking to
address homelessness among African Americans may require special consideration of institutional and
structural contexts. Second, they demonstrate that examination of the specific needs of subgroups of
homeless people must not stop at descriptions of individual susceptibilities, but must also examine group-
specific social issues.

Homelessness Among Latinos

The under-representation of latinos among homeless people in spite of their high poverty levels has been
deftly explored by Susan Gonzalez Baker (1996) who coined the phrase "The Latino Paradox". She
suggested four possible explanations for the low numbers of latinos among the homeless: (1) survey
methods may systematically undercount latinos in homeless samples, (2) latinos may have lower levels of
personal risk factors such as psychiatric or substance abuse disorders that reduce their risk of
homelessness, (3) latinos may face fewer social disadvantages than other groups, particularly compared
to blacks and (4) exceptionally strong traditions of mutual familial support may be protective against
homelessness. Baker suggests that the evidence does not support survey bias or differences in personal
risk factors, although a recent epidemiologic study conducted in California suggested that mental illness
was far less common among new immigrants than among those who had been in this country for many
years or had been born here (Vega et al., 1998). Although not definitive, available data most strongly
suggest that latinos may be subject to less housing and job discrimination than blacks, and that they are
more likely to incorporate additional family members in a single household (Greene & Monahan, 1984;
Mindel, 1980).

In the brief period since Baker's study, considerable attention has been focused on the large and growing
number of hispanic immigrants in this country, both legal and illegal, especially in California and the
Southwest. Originally "invited" to provide a new source of low-wage labor, the rapidly growing numbers
of immigrants from Latin America has generated a formidable backlash (Suro, 1997). Studies of the new
immigrants have documented several characteristics that may affect their risk for homelessness. (1)
Immigrants from the same towns in Latin America are tightly bound to one another and are deeply

National Symposium on Homelessness Research 2-15

Special Populations of Homeless Americans

committed to mutual protection (Suro, 1998). (2) They are often apprehensive about using conventional
governmental services for fear of being identified as illegal residents (either correctly or incorrectly).
Finally, epidemiologic studies suggest that recent migrants, especially those in the Southwest, have fewer
health problems (including mental health problems) than latinos who were born in this country (Vega et
al., 1998).

A recent study from the Northeast, however, also found that Puerto Rican single mothers who were poor
had experienced less violence and had fewer mental health problems (with the exception of major
depression) than whites (Bassuk, Perloff & Coll, 1998). Each of these factors could result in a reduced
risk of homelessness among recent immigrants and among less acculturated latinos. Little is known
about the specific risk of homelessness among recent immigrants. The possibility that the Latino paradox
may reflect specific conditions faced by more recent immigrants will hopefully generate additional
discussion and research. The findings of Vega et al., (1998) may suggest that as acculturation proceeds,
the risk of homelessness among latinos may become similar to that of the impoverished populations.

Native Americans Among the Homeless

Although blacks and latinos are the most numerous minority groups in this country, they are not the only
ones that face adverse circumstances. The presence of other subgroups among the homeless and the
documentation of their needs have received minimal attention. We note, however, a large national study
of homelessness among Native American veterans because it further illustrates many of the themes we
have been exploring (Kasprow & Rosenheck, 1998). This study of almost 50,000 homeless veterans
showed that Native Americans are substantially overrepresented among homeless veterans (even without
considering the prevalence of homelessness on reservations) and that, unlike other groups, they suffer
overwhelmingly from alcohol abuse, with far lower rates of diagnosed psychiatric disorders. Alcohol
abuse has been widely identified as a substantial problem in Native American populations, and is viewed
by many as one consequence of the genocidal treatment of Native Americans by European conquerors
(White, 1992).

Homelessness and Health: Psychiatric, Substance Abuse and Medical Disorders

As in our review of literature on generational, gender and familial circumstances and needs of homeless
persons, we have found that examination of racial and ethnocultural subgroup experiences also reveal
both distinctive vulnerabilities and service needs specific to each subgroup, as well as more common
experiences of social disadvantage and personal deprivation. As we turn to an examination of illness,
and specifically mental illness among homeless people, we move from issues which reflect major
features of societal organization that have received only limited attention, to issues that have been at the
center of public understanding of the problems of homeless people and have been thoroughly and
carefully researched.

The prevalence of psychiatric and addictive disorders among homeless people has probably been studied
more intensively and more rigorously than any other problem. Early accounts suggested that as many as
90 percent of homeless people might be suffering from mental illnesses — including many with severe
illnesses such as schizophrenia and other psychoses (Bassuk, Rubin & Lauriat, 1984). Many critics
quickly identified the deinstitutionalization of people with mental illness from state hospitals as a major
"cause" of homelessness in the 1980s (Koegel, Burnam & Baumohl, 1996). Others pointed out that both
sampling and diagnostic tools used in early studies of mental illness among homeless people were
seriously inadequate, and that the timing of deinstitutionalization could not directly implicate it as a
direct cause of homelessness.

2-16 National Symposium on Homelessness Research

Special Populations of Homeless Americans

In the mid-1980s the National Institutes of Mental Health funded a series of rigorous epidemiological
studies based on systematic sampling strategies and state-of-the-art assessment methods. These studies
demonstrated that 20-25 percent of homeless single adults had lifetime histories of serious mental illness;
about half had histories of alcohol abuse or dependence; and about one-third had histories of drug abuse
or dependence (Susser, Struening, & Conover, 1989; Breakey et al., 1989; Koegel, Bumam & Farr,
1989). While these rates of lifetime mental illness were 3-5 times greater than rates in the general
population, these studies demonstrated that most homeless people did not have serious mental illnesses,
and that less than 15 percent had suffered from schizophrenia (Koegel, Burnam & Baumohl, 1996;
Tessler & Dennis, 1989). Although far more modest than rates reported in previous studies, these data
clearly showed that severely mentally ill people were at much higher risk for homelessness than others
and that they endured homelessness for greater periods of time. Because the public believed that the
needs of people with serious mental illness had not been adequately addressed by the community mental
health movement, and because it was more widely accepted that people with serious mental illness "can't
help themselves," the public has been willing to support outreach programs to facilitate the entry of
distrustful homeless people with mental illness into programs.

Alcoholism has long been identified as a central feature of the lives of homeless people and an
explanation for their homelessness (Bahr & Caplow, 1973; Wiseman, 1973). However, among the
homeless people who became visible during the 1980s, alcohol addiction was often found in younger
members of minority groups (Koegel & Burnam, 1987) and among people with concomitant mental
illness. About half of those with serious mental illness also had substance abuse disorders — the so-called
dually diagnosed (Drake, Osher & Wallach, 1991). Alcohol abuse and dependence were often combined
with the use of illicit drugs, especially crack cocaine (Jencks, 1994). Because crack cocaine was much
cheaper than other drugs and other forms of cocaine, it was widely used by low income people during the
years after 1984.

The high level of addictiveness of crack cocaine resulted in sustained, widespread use; one survey found
66 percent of anonymous urines collected in a New York City homeless shelter were positive for crack
cocaine (Jencks, 1994). While the path from alcoholism to homelessness was not a new one, the path
from crack cocaine to homelessness was new, and was markedly facilitated by the low cost of the drug.
Here, too, it affected the poor, infirm, and disadvantaged with special harshness.

In addition to the high rates of alcohol, drug, and mental disorders, homeless people also suffer from
serious medical infirmities and experience mortality rates as much as twice a great as those of poor,
domiciled people with mental illness (Kasprow and Rosenheck, 1998). The rate of HIV infection is
especially high among homeless people. One study conducted in a New York City men's shelter found
that 19 percent of homeless mentally ill men were HIV positive (Susser, Valencia & Conover, 1993)
while another found 62 percent of homeless men were HIV positive and 18 percent had active
tuberculosis (Torres et al., 1990). Another large study of New York City shelter users found that use of
drugs, alcohol, and the presence of psychiatric disorder are all associated with poorer physical health,
even distinct from specific illnesses such as HIV, and that the physical health status of homeless men is
well below that of community samples (Streuning & Padgett, 1990).

Homelessness is thus both an effect and a cause of serious mental and physical health care problems. On
the one hand, survey data strongly suggest that people with physical and mental infirmities are far more
likely to become homeless than others. On the other hand, the exposure to the elements, poor nutrition,
and lack of basic comforts experienced by homeless people worsens their already compromised health
status. There is little question that homeless people need health services well beyond those they receive
through conventional channels. The mentally ill among homeless people are often the most demoralized

National Symposium on Homelessness Research 2-17

Special Populations of Homeless Americans

and hopeless, and least convinced that they can improve their situation. Supportive case management
within a sustained healing relationship is an especially important component of services for this segment
of the population.

Homeless People with Special Status in Society

Homeless Veterans

For as long as there have been armed forces, veterans have been honored and received considerable
public attention and concern. Since the development of citizen armies in the 19th century, in recognition
of their service and sacrifice, their power as a political force, and the potential threat they pose to social
order, veterans have had a unique status in society (Severo & Milford, 1989). Surveys conducted during
the 1980s indicated that as many as half of homeless veterans served during the Vietnam era compared to
only one-third of veterans in the general population. These estimates led many to suggest that
homelessness among veterans might be yet another consequence of military service during the Vietnam
War and, more specifically, of combat-related posttraumatic stress disorder (PTSD) (Robertson, M,
1987). Although studies have clearly shown that some Vietnam veterans have suffered prolonged
psychological problems related to their military service, the assumption that homelessness among
veterans is primarily related to Vietnam service is not supported by available evidence.

A systematic synthesis of survey data indicated that 40 percent of homeless men report past military
service, as compared to 34 percent in the general adult male population (Rosenheck et al., 1994), a
modest increase in risk. Further studies using numerous, diverse data sets show that homeless veterans
are not more likely to have served during wartime or in combat than age-matched peers who were not
homeless, and were no more likely to have war-related posttraumatic stress disorder than non-homeless
low income veterans (Rosenheck et al., 1996). A causal model of the genesis of homelessness among
veterans also found that while mental illnesses other than PTSD, substance abuse, and social isolation
were significantly related to homelessness, combat exposure and PTSD were not major predictors
(Rosenheck & Fontana, 1984). In fact, the subgroup of veterans at greatest risk of homelessness as
compared to their non-veteran peers are those who served after the Vietnam war, during the initial period
of the All Volunteer Army, when the military was unpopular, paid low salaries, and was forced to admit
many poorly adjusted recruits (Rosenheck, Frisman & Chung, 1984).

Studies conducted during the 1980s consistently reported that homeless veterans were older and are more
likely to be white than other homeless men (Roth et al., 1992; Schutt et al., 1986; Streuning &
Rosenblatt, 1987; Robertson, 1987). Some of these studies also reported that homeless veterans had
more often been in jail than homeless non-veterans, were more likely to have problems related to alcohol
use, or are more likely to have been hospitalized for a psychiatric or a substance abuse problem. A re-
analysis of data from three surveys conducted during the late 1980s found that homeless veterans were
older than non- veterans; more likely to be white; better educated; and more often previously or currently
married, but were not different on indicators of residential instability, current social functioning, physical
health, mental illness or substance abuse (Rosenheck & Koegel, 1993). Thus, it appears that the personal
risk of homelessness among veterans was due primarily to the same factors as homelessness among other
Americans — poverty, joblessness, mental illness and substance abuse.

However, homeless veterans have received considerable special attention and some degree of incremental
service funding because of their past service to society. A headline in USA Today , for example, hailed "a
shattered army: 500,000 homeless veterans most of whom served in Vietnam," a degree of sympathetic
attention not granted to other subgroups of the homeless. Secretary of Veterans Affairs Jesse Brown told

2-18 National Symposium on Homelessness Research

Special Populations of Homeless Americans

the Congress that homelessness among veterans "is an American tragedy.... The way a society treats its
veterans is an indication of who we are as a nation." It is unlikely that any other cabinet officer has
spoken as feelingly or as convincingly about a particular subgroup of the homeless.

Criminal Justice System Users

In dramatic contrast to the public's view of veterans are the feelings about the large numbers of homeless
persons who have past histories of involvement in the criminal justice system (Fisher, 1992; Gelberg,
Linn & Leake, 1988). An estimated 20 percent to 66 percent of homeless people have been arrested or
incarcerated in the past as compared to only 22 percent of men and 6 percent of women in the general
population (Fisher, 1992). These high rates may reflect one of four distinct personal configurations: (i)
long-term deviant life styles (people who are deeply involved in crime and antisocial behavior as a way
of life, including drug abuse); (ii) subsistence (the need to commit crimes for material sustenance); (iii)
adaptation (criminal behavior as a necessary part of adjusting to life on the street), or (iv) diminished
capacity (crime resulting from the inability to tell right from wrong due to mental illness). Reliable
estimates of the relative importance of these four patterns among homeless people are not available,
although they have different implications for social policy. Long term deviant life styles, for example,
might suggest the need for increased incarceration while the diminished capacity explanation suggests
targeting additional treatment resources to the homeless.

One author points out that the rise in homelessness during the 1980s corresponds closely to the increase
in numbers of prison inmates (O' Flaherty, 1996). Between 1974 and 1984, for example, the prison
population of New York State increased 2.3 times — from 12,532 to 28,992. In this view, personal
characteristics are less central that social policy in explaining the large numbers of criminal justice
system users among the homeless. By incarcerating a growing proportion of poor, often drug abusing,
largely minority, citizens, criminal justice policy cut these vulnerable citizens off from the communities
from which they came, unintentionally reducing the likelihood that they would ever be able to reestablish
themselves after their release from jail or prison. Homelessness among former inmates may reflect an
unanticipated negative consequence of a failed solution to a misunderstood social problem.

From another perspective, however, it has been observed that the criminal histories of many homeless
people primarily reflect arrests that occurred after they became homeless — arrests for stealing or
disturbing the peace that are an intrinsic part of life in public spaces (Fisher, 1992; Snow et al., 1989).
Here, too, we have little information on the relative importance of each of these processes, but it is
important to note the dramatic contrast between interpretations that view homeless people with past
histories of involvement in the criminal justice system as victims of societal mistreatment, as contrasted
with interpretations that emphasize behavioral deviance as determined at the individual level (Benda,
1987; Martell & Elliott, 1992; Martell, Rosner & Harmon, 1995).

Considerable emphasis has been placed in the literature on the possibility that people with serious mental
illness are being referred with increasing frequency to the criminal justice system because of the
inadequacies of the mental health system (Torrey et al., 1992). Advocates have suggested expanding jail
diversion programs to appropriately channel people with mental illness to the mental health, rather than
criminal justice system (Steadman, Barbera & Dennis, 1994).There is a considerable need for further
research on the interrelationship of homelessness, mental illness, minority status and involvement in the
criminal justice system.

National Symposium on Homelessness Research 2-19

Special Populations of Homeless Americans

Illegal Immigrants

We conclude this section by describing a subgroup of homeless people whom virtually nothing has been
written: illegal immigrants. While this population has been growing rapidly and has provoked a harsh
backlash reflected in the passage of Proposition 187 in California in 1994 (Suro, 1998), we know of only
clinical anecdotes revealing the presence of such people among the homeless. Little is known about this
population for the following reasons: (i) they may not be very numerous, (ii) they may be unwilling to
identify themselves for fear of being deported, and (iii) they receive little attention because they have the
least claim on our sympathies (a point deeply underscored by the passage of Proposition 187). To better
serve this group, additional information about their needs is necessary.

Summary: Heroes, Deviants, and the Invisible

In this brief survey of homelessness among veterans, users of the criminal justice system, and illegal
immigrants we have described three subgroups that cross social status levels: from some of the most
idealized members of society, to some of the most despised, to the largely ignored. And yet survey data
suggest that the boundaries among these groups may be much clearer in the public imagination than in
reality. In a sample of over 10,000 homeless mentally ill veterans seen in a national Congressionally
funded VA program, one-third of whom had served the nation in combat, over 50 percent of the sample
had significant criminal justice histories (Rosenheck et al., 1989); in fact, they differed little from other
homeless men in this or any other respect. The parable of the good Samaritan urges us to care for
strangers just as we would care for our closest relatives. In our reflection on homelessness among these
three subgroups we confront most dramatically the tension between attending to each subgroup in order
to better understand and respond to their needs — or to differentiate among them to best decide who are
deserving of public provision and who are not.

Discussion

In this presentation we have reviewed research on the diverse needs of various subgroups of homeless
people. While we have discussed the distinct needs of each subgroup, we have also provided evidence
indicating that the most effective way of preventing homelessness is to directly provide residential
services and adequate income support. Although many homeless subgroups, especially the young and the
mentally ill need personal support and remoralization to take full advantage of expanded opportunities,
the late 1970s and early 1980s was not a time of epidemic demoralization, but of structural change in our
society.

Why then have we focused on subgroup characteristics? To answer this question, we must briefly review
American attitudes and public policy towards social support for the disadvantaged. Between the 1880s
and 1920s the major industrial nations outside of the United States guaranteed protection for all citizens
against insufficient income due to old age, disability, illness, or unemployment (Weir, Orloff & Skocpol,
1988a; Skocpol, 1992; Wilensky & Lebeaux, 1965; Rimlinger, 1971). Programs for workman's
compensation, old age pensions and insurance, health insurance, unemployment insurance, and mother's
insurance were instituted not just to attack poverty, but to generate a form of social citizenship that
guaranteed basic rights and expressed the solidarity of national community (Heclo, 1995). For various
cultural (Rimlinger, 1971) and political reasons (Weir, Orloff & Skocpol, 1988a; Skocpol, 1992) a broad
commitment to social welfare never developed in the United States.

2-20 National Symposium on Homelessness Research

Special Populations of Homeless Americans

For example, in the mid-1980s in five European nations, Australia, and Canada, 23 percent of the
population would have lived in poverty without welfare benefits. However, only 5 percent were poor as
a result of government benefits, a reduction of 18 percent which was attributable to public provision. In
contrast, in the United States, 20 percent of the population would have lived in poverty without welfare
benefits; 13 percent remained in poverty even after consideration of benefits, a drop of only 7 percent
(Mischel & Bernstein, 1993). While European nations spent an aggregate of 20 percent of GDP on social
welfare programs in the mid-1980s, the US spent only 16 percent (Weir, Orloff & Skocpol, 1988a).

These statistics reflect deeply held American attitudes. While other industrial nations have maintained a
broad commitment to social provision for their citizens — even as they have reduced the generosity of
benefits in recent years — the United States has long questioned the motives and deservingness of its poor
(Katz, 1989). In fact, Americans have reduced their national commitment through various welfare
reform measures and retrenchments (Mishel & Bernstein, 1993). The American approach to public
assistance has traditionally been based on a critical evaluation of deservingness, rather than on a broad
commitment to assisting the economically disadvantaged. The current withdrawal of public support has
occurred in the face of compelling evidence that the distribution of income has become increasingly
inequitable since the mid 1970s, and that earning opportunities for unskilled workers continue to
diminish even in a booming economy (Passell, 1998).

It is not surprising that within this context the differential composition of the homeless population in
America receives so much attention. While in other wealthy industrial countries, the mere fact of
homelessness justifies a public response, the traditions of social provision in this country demand further
justification of the claim for public sympathy and support for each specific subgroup of homeless people.
In a broad empirical review of the performance of the U.S. Government, former President of Harvard
University, Derek Bok, concluded that while our country excels above all others in its productivity and
high standard of living, and that our government is both effective and efficient, it does less well than
other countries at protecting its citizens and assuring their personal security (Bok, 1997, p. 63-64).

Convincing others that people are deserving of assistance requires that researchers specializing in the
problems of each subgroup advocate for the legitimacy of their needs. This also may explain why so
much scholarly attention is directed at subgroups of the homeless who are regarded as "deserving":
families, children, the severely mentally ill, and veterans. Little emphasis is placed on other subgroup
characteristics such as extreme poverty, minority status, or being an illegal immigrant.

We do not mean to underplay the importance of addressing the pressing needs of subgroups of the
homeless. Children must be educated, single mothers must have child care and job training, the mentally
ill need treatment for their illnesses, and veterans deserve honor and recognition for their past sacrifices.
All the disadvantaged need encouragement and support (Bardach, 1997). But the studies we have
reviewed suggest that as important as these specialized services are, they are not the most effective way
out of homelessness. That data strongly indicate that all services must be targeted to the specific needs
of individual clients, and that emphasizing subgroup characteristics and needs should in no way imply a
de facto acceptance of homelessness itself as irremediable and therefore, as acceptable. Since we as a
people are not committing the funds to provide subsistence resources for the poor, we understand that
there will continue to be hundreds of thousands of homeless persons on any given night, and we are
resigned to providing for their educational, health care and job training needs within that context. To do
so is certainly preferable to neglecting those needs. However, it is imperative that policy makers
understand that such a response may reflect capitulation to an outcome that is not inevitable. If the
political will were present, homelessness could be eradicated or at the very least, very markedly reduced.

National Symposium on Homelessness Research 2-21

Special Populations of Homeless Americans

References

Alperstein, G., Rappaport, C. & Flanigan, J. M. (1988). Health Problems of Homeless Children in New
York City. American Journal of Public Health, 78: 1232-1233.

American Medical Association Council on Scientific Affairs. (1989). Health Care Needs of Homeless
and Runaway Youths. The Journal of the American Medical Association, 262: 1358-1361.

Bachrach, L. (1987). Homeless Women. A Context for Health Planning. The Milbank, Quarterly, 65:
371-395.

Bahr, H. M. & Caplow, T. T. (1973). Old Men Drunk and Sober. New York, NY: New York University
Press.

Baker, S. G. (1996). Homelessness and the Latino Paradox. In J. Baumohl (Ed.) Homelessness in
America: A Reference Book. Phoenix, AZ: Oryx Press.

Bardach, E. (1997). Implementing a Paternalistic Welfare-to-Work Program. In L. Mead (Ed.), The
New Paternalism: Supervisory Approaches to Poverty. Washington, DC: Brookings.

Bassuk, E. L. (1995). Lives in Jeopardy: Women and Homelessness. In C. Willie, P. P. Rieker, B.
Kramer & B. Brown. Mental Health, Racism and Sexism. Pittsburgh: University of Pittsburgh Press,

237-252.

Bassuk, E. L. & Franklin D. (1992). Homelessness Past and Present. The Case of the United States,
1890-1925. New England Journal of Public Policy. 8: 67-85.

Bassuk, E. L. & Gallagher, E. (1990). The Impact of Homelessness on Children. Child and Youth
Services, 14: 19-33.

Bassuk, E. L. & Harvey, M. R. (1990). Family Homelessness. Recommendations for a Comprehensive
Policy Response. In E. L. Bassuk, R. Carman, & L. Weinreb, Community Care for Homeless Families:
A Program Design Manual. Washington DC: Interagency Council on the Homeless.

Bassuk, E. L. & Rosenberg, L. (1990). Psychosocial Characteristics of Homeless Children and Children
with Homes. Pediatrics, 85: 257-261.

Bassuk, E. L. & Weinreb, L. (1993). Homeless Pregnant Women: Two Generations at Risk. American
Journal of Orthopsychiatry. 63: 348-357.

Bassuk, E. L., Browne, A. & Buckner, J. C. (1996). Single Mothers and Welfare. Scientific American.
275: 60-67.

Bassuk, E. L., Buckner, J. C, Weinreb, L. F., Browne, A., Bassuk, SS, Dawson, R. & Perloff, J. N.
(1997). Homelessness in Female-Headed Families: Childhood and Adult Risk and Protective Factors.
American Journal of Public Health, 87: 241-248.

Bassuk, E. L., Perloff, J. N. & Coll, C. G. (1998). The Plight of Extremely Poor Puerto Rican and Non-
Hispanic White Single Mothers. Social Psychiatry and Psychiatric Epidemiology, 33: 326-336.

2-22 National Symposium on Homelessness Research

Special Populations of Homeless Americans

Bassuk, E. L., Rubin, L. & Lauriat, A. (1984). Is Homelessness a Mental Health Problem? American
Journal of Psychiatry 141: 1546-1555.

Bassuk, E. L., Weinreb, L. F., Buckner, J. C, Browne, A., Salomon, A., Bassuk, S. S. (1996). The
Characteristics and Needs of Sheltered Homeless and Low-Income Housed Mothers. Journal of the
American Medical Association, 276: 640-646.

Bassuk, E. L., Weinreb, L., Dawson, R., Perloff, J. N. & Buckner, J. C. (1997b). Determinants of
Behavior in Homeless and Low-Income Housed Preschool Children. Pediatrics, 700(1): 92-100.

Baumohl, J. (Ed.) (1996). Homelessness in American: A Reference Book. Phoenix, AZ: Oryx Press.

Bell, D., Kasschau, P. & Zellman, G. (1976). Delivering Services to Elderly Members of Minority
Groups: A Critical Review of the Literature. Santa Monica, CA: Rand Corporation.

Benda, B. B. (1987). Crime, Drug Abuse, Mental Illness and Homelessness. Deviant Behavior, 8: 361-
375.

Bok, D. (1997). Measuring the Performance of Government. In J. S. Nye, P. D. Zelikow & D. C. King
(Eds.) Why People Don 't Trust Government. Cambridge, MA: Harvard University Press.

Boondas, J. (1985). The Despair of the Homeless Aged. Journal of Gerontological Nursing, 1 7(4):
645-652.

Bowling, B. (1991). Ethnic Minority Elderly People: Helping The Community to Care. New
Community, 77(4): 645-652.

Boxill, N. A. & Beaty, A. L. (1990). Mother Child Interaction among Homeless Women and Their
Children in a Public Night Shelter in Atlanta, Georgia. Child and Youth Services, 14: 49-64.

Breakey, W. R., Fischer, P. J., Kramer, M., Nestadt, G., Romanoski, A. J., Ross, A., Royal, R. M. &
Stine, O. C. (1989). Health and Mental Health Problems of Homeless Men and Women in Baltimore.
Journal of the American Medical Association, 262: 1352-1357.

Buckner, J. & Bassuk, E. L. (in press). Family Homelessness in America. In P. Vostanis & S. Cumella
(Eds.), Homeless Children: Problems and Needs. London: Jessica Kingsley Publishers.

Buckner, J. C. & Bassuk, E. L. (1997). Mental Disorders and Service Utilization Among Youths Form
Homeless and Low-Income Housed Families. Journal of the American Academy of Child and
Adolescent Psychiatry, 36 (7): 890-900.

Burt, M. F., Cohen, B. E. (1989). Differences among homeless single women, women with children and
single men. Social Problems 36: 508-524.

Burt, M. R. (1992). Over the Edge: The Growth of Homelessness in the 1980s. New York, Russell Sage
Foundation.

National Symposium on Homelessness Research 2-23

Special Populations of Homeless Americans

Calsyn, R. & Morse, G. (1990). Homeless Men and Women: Commonalities and a Service Gender Gap.
American Journal of Community Psychology 18: 597-608.

Camino, L. A., & Epley, K. A. (1998). Having a Place to Call Home. National Network for Youth &
W. K. Kellogg Foundation Conference, Washington, DC, April 7-9.

Cohen, C .1., Ramirez, M., Teresi, J., Gallagher, M., & Sokolovsky, J. (1997). Predictors of Becoming
Redomiciled Among Older Homeless Women. The Gerontologist, 37{\): 61-1 A.

Cohen, C. I., Teresi, J., Holmes, D., & Roth, E. (1988). Survival Strategies of Older Homeless Men.

Gerontologist, 28: 58-65.

Cohen, N.L., & Sullivan, A. M. (1990). Strategies of Intervention and Service Coordination by Mobile
Outreach Teams. In N.L. Cohen (Ed.), Psychiatry Takes to the Streets: Outreach and Crisis Intervention
for the Mentally III. New York: The Guilford Press.

Crane, M. (1994). Elderly Homeless People: Elusive Subjects and Slippery Concepts. Aging and
Society, 14: 631-640.

Crystal, S. (1984). Homeless Men and Homeless Women: The Gender Gap. Urban and Social Change
Review, 17: 2-6.

Culhane, D. & Kuhn R. (1998). Patterns and Determinants of Public Shelter Utilization Among
Homeless Adults in New York City and Philadelphia. Journal of Policy Analysis and Management,
77(1): 23-43.

Danziger, S., & Daniger, S. (1993). Child Poverty and Public Policy: Toward a Comprehensive
Antipoverty Agenda. Daedalus: America's Childhood, 122: 57-84.

Doolin, J. (1986). Planning for the Special Needs of the Homeless Elderly. The Gerontologist, 25(3):
229-231.

Douglass, R. (1988). Aged, Alone, and Adrift. Detroit, MI: Detroit Area Agency on Aging.

Drake, R. E., Osher, F. & Wallach, M. A. (1991). Homelessness and Dual Diagnosis. American
Psychologist 46{U): 1 149-1 158.

Duncan, G., & Brooks-Gunn, J. (Eds.). (1997). Consequences of Growing Up Poor. New York: Russell
Sage Foundation.

Edelman, M. W. & Mihaly, L. (1989). Homeless Families and the Housing Crisis in the United States.
Children and Youth Services Review, 11: 91-108.

Erikson, E. (1963). Children and Society, Second Edition. New York: W.W. Norton.

Erikson, E. (1986). Vital Involvement in Old Age: The Experience of Old Age in Our Time. New York:
W.W.Norton.

Farrow, J. A., Deisher, R. W., & Brown, R. (1991). Introduction. Journal of Adolescent Health, 12:

497-499.

2-24 National Symposium on Homelessness Research

Special Populations of Homeless Americans

Fisher P. J. (1992). The Criminalization of Homelessness. In Robertson M. J. & Greenblatt M. (eds.)
Homelessness: A National Perspective. New York: Plenum Press.

Fisher, P. J. (1991). Alcohol, Drug Abuse and Mental Health Problems Among Homeless Persons: A
Review of the Literature, 1980-1990. Washington, DC: Alcohol, Drub Abuse, and Mental Health
Administration.

Gelberg, L., Linn, L. S., & Leake, B. D. (1988). Mental Health, Alcohol and Drug Use, and Criminal
History Among Homeless Adults. American Journal of Psychiatry 145(2): 191-196.

Gilderbloom, J. I., & Mullins, R. L. (1995). Elderly Housing Needs: An Examination of the American
Housing Survey. International Journal Aging and Human Development, 40(1): 57-72.

Goodman, L, Saxe, L & Harvey, M. (1991). Homelessness as a Psychological Trauma. American
Psychologist. 46: 1219-1225.

Greene V L & Monahan D J (1984). Comparative Utilization of Community-Based Long-Term Care
Services by Hispanic and Anglo Elderly in a Case Management System. Journal of Gerontology 39:
730-735. *

Hagen, J. & Ivanoff, A. (1988). Homeless Women, A High-Risk Population. Affilia. 3: 19-33.

Hausman, B. & Hammen, C. (1993). Parenting in Homeless Families: The Double Crisis. American
Journal of Orthopsychiatry. 63: 358-369.

Kasprow, W. J. & Rosenheck, R. A. (1998). Morality Among Homeless and Domiciled Veterans With
Mental Disorders.

Kasprow, W. J. & Rosenheck, R. A. (1998). Substance Use and Psychiatric Problems of Homeless
Native American Veterans. Psychiatric Services 49 (3): 345-350.

Katz, M. (1989). The Undeserving Poor: From the War on Poverty to the War on Welfare. New York,
NY: Pantheon.

Keigher, S. M., Ahrens, R. J., & Lumpkin, R. (1987). The City's Responsibility for the Homeless
Elderly in Chicago. Chicago: Final Fellowship Report.

Kipke, M. D., Unger, J. B., Palmer, R., & Edgington, R. (1997). Drug-Injecting Street Youth: A
Comparison of HIV-Risk Injection Behaviors Between Needle Exchange Users and Nonusers. AIDS and
Behavior, 1(4): 225-232.

Knickman, J. & Weitzman, B. C. (1989). Homeless Families in New York City: An Assessment of
Factors That Increase Risk of Shelter Use. New York: Human Resources Administration.

Koegel, P. & Burnam, M. A. (1987). Traditional and Nontraditional Homeless Alcoholics. Alcohol
Health and Research World 11(3): 28-33.

Koegel, P., Burnam, M. A., Baumohl, J. (1996). The Causes of Homelessness in Homelessness in
America. Ed. Jim Baumohl, New York, NY: Oryx Press.

National Symposium on Homelessness Research 2-25

Special Populations of Homeless Americans

Koegel, P., Burnam. A., & Fair, R. (1989). The Prevalence of Specific Psychiatric Disorders Among
Homeless Individuals in the Inner-City of Los Angeles. Archives of General Psychiatry, 45: 1085-1092.

Kutza, E. A., & Keigher, S. M. (1991). The Elderly "New Homeless": An Emerging Population At
Risk. Social Work, 36(4): 288-293.

Ladner, S. (1992). The Elderly Homeless. In Robertson, M.J. & Greenblatt, M. (Eds.), Homelessness:
A National Perspective. New York: Plenum Press.

Leda, C. & Rosenheck, R. A. (1995). Race in the Treatment of Homeless Mentally 111 Veterans.
Journal of Nervous and Mental Disease 183: 529-537.

Lindsey, E. W., Jarvis, S., Kurtz, P. D., & Nackerud, L. (1998). Navigating Troubled Waters: How
Runaway and Homeless Youth Are Able to Create Success in Their Lives. Unpublished manuscript.

Martell, D. A. & Elliott, P. (1992). Mentally Disordered Offenders Who Push or Attempt to Push
Victims on Subway Tracks in New York City. Archives of General Psychiatry 49: 472-475.

Martell, D. A., Rosener, R. & Harmon, R. B. (1995). Base-Rate Estimates of Criminal Behavior by
Homeless Mentally 111 Persons in New York City. Psychiatric Services 46(6): 596-601.

Martin, M. A. (1990). The Homeless Elderly: No Room At the End. In Z. Harel, P. Ehrlich & R.
Hubbard, The Vulnerable Aged: People, Services, and Policies. New York: Springer Publishing
Company.

Massey, D. S. & Denton, N. A. (1993). American Apartheid: Segregation and the Making of the
Underclass. Cambridge, MA: Harvard University Press.

Masten, A. S., Miliotis, D., Graham-Berman, S. A., Ramirez, M. & Neemann, J. (1993). Children in
Homeless Families: Risks to Mental Health and Development. Journal of Consulting and Clinical
Psychology, 61: 335-343.

McLoyd, V. C. (1998). Socioeconomic Disadvantage and Child Development. American Psychologist,
53(2): 185-204.

Merves, E. (1992). Homeless Women. Beyond the Bag Lady Myth. In M. Robertson & M. Greenblatt
(Eds.). Homelessness. A National Perspective. New York: Plenum Press, 229-244.

Miller, D., Hoffman, F., & Duggan, R. (1980). Runaways - Illegal Aliens in Their Own Land. Brooklyn,
NY: Praeger Publishers.

Mindel, C. H. (1980). Extended Familism Among Urban Mexican Americans, Anglos and Blacks.
Hispanic Journal of Behavioral Sciences 20: 21-34.

Mishel, L. & Bernstein, J. (1993). The State of Working America: 1992-3. Armonk, NY: ME Sharpe.

Molnar, J. & Rath, W. (1990). Constantly Compromised: The Impact of Homelessness in Children.
Journal of Social Issues, 46: 109-124.

2-26 National Symposium on Homelessness Research

Special Populations of Homeless Americans

National Network of Runaway and Youth Services Inc. (1985). To Whom Do They Belong] A Profile of
America 's Runaways and Homeless Youth and the Programs That Help Them. Washington, D.C.:
National Network of Runaway and Youth Services, Inc.

O'Connell, J. J. (1990). Caring for the homeless elderly. Pride Institute Journal of Long Term Home
Health Care, 9(1): 20-25.

O'Flaherty, B. (1996). Making Room: The Economics of Homelessness. Cambridge, MA. Harvard
University Press.

Oliver, M. L. & Shapiro, T. M. (1995). Black Wealth/White Wealth: A New Perspective on Racial
Inequality. New York, NY: Routledge

Parker, R., Rescorla, L., Finklestein, J., et al. (1991). A Survey of the Health of Homeless Children in
Philadelphia Shelters. American Journal of Adolescent and Child Psychiatry, 145: 520-526.

Passell, P. (1998) Benefits Dwindle Along With Wages for the Unskilled. New York Times: Al, June
14.

Pennbridge, J., Yates, G., David, T., & Mackenzie, R. (1990). Runaway and Homeless Youth in Los
Angeles County, California. Journal of Adolescent Health Care, IT. 159-165.

Powers, J. L., & Jaklitsch, B. (1993). Reaching the Hard to Reach: Educating Homeless Adolescents in
Urban Settings. Education and Urban Society, 25(4): 394-409.

Rafferty, M. A. (1986). The Elderly: the Role of Nurses in Meeting Health/Mental Health Needs of the
Homeless. Proceedings of National Institute of Mental Health March 6-8 Workshop, 33-35: 179-192.
Washington, DC: U. S. Department of Health and Human Services.

Rafferty, Y., & Shinn, M. (1991). The Impact of Homelessness on Children. American Psychologist,
46: 1170-1179.

Rimlinger, G. (1971). Welfare Policy and Industrialization in Europe, America and Russia. New York,
NY: Wiley.

Robertson, M. (1987). Homeless Veterans: An Emerging Problem? In R D Bingham, R. e. Green & S.
B. White (Eds.). The Homeless in Contemporary Society. Beverly Hills, CA: Sage Press

Robertson, M. (1989). Homeless Youths: Patterns of Alcohol Use. Berkeley, CA: Alcohol Research
Group.

Robertson, M. (1991). Homeless Youths: An Overview of Recent Literature. In J. Kryder-Coe, L.
Salmon, & J. Molnar (Eds.), Homeless Children and Youth: A New American Dilemma. New
Brunswick; London: Transaction Publishers, 33-68.

Robertson, M. J. & Greenblatt, M. (1992). Homelessness: A National Perspective. New York: Plenum
Press.

Robertson, M. J., Koegel, P., & Ferguson, L. (1989). Alcohol Use and Abuse Among Homeless
Adolescents in Hollywood, Contemporary Drug Problems, Fall: 415-452,

National Symposium on Homelessness Research 2-27

Special Populations of Homeless Americans

Rog D. J., McCombs-Thornton K. L., Gilbert-Mongelli, A. M„ Brito M. C, Holupka C S. (1995b).
Implementation of the Homeless Families Program: 2. Characteristics, Strengths and Needs of
Participant Families. American Journal of Orthopsychiatry. 65: 514-527.

Rog, D. J., Holupka S, McCombs-Thornton MPP. (1995a). Implementation of the Homeless Families
Program: Service Models and Preliminary Outcomes. American Journal of Orthopsychiatry 65: 502-
513.

Rog, D. J., McCombs-Thornton, K. L., Gilbert-Mongelli, A. M., Brito, M. C, & Holupka, C. S. (1995).
Implementation of the Homeless Families Program: 2. Characteristics, Strengths, and Needs of
Participant Families. American Journal of Orthopsychiatry, 65(4), 514-528.

Rosenheck, R. A. & Koegel, P. (1993). Characteristics of Veterans and Nonveterans in Three Samples
of Homeless Men. Hospital and Community Psychiatry 44: 858-863

Rosenheck, R. A., Frisman, L. K. & Chung, A. (1994). The Proportion of Veterans Among the
Homeless. American Journal of Public Health 84 (3): 466-468

Rosenheck, R. A., Leda, C, Frisman, L. K. & Gallup, P. (1997). Homeless Mentally 111 Veterans: Race,
Service Use and Treatment Outcome. American Journal of Orthopsychiatry 67(4): 632-639.

Rosenheck, R. A., Leda, C, Frisman, L. K., Lam, J. & Chung, A. (1996). Homeless Veterans. In J.
Baumohl (Ed.) Homelessness in America: A Reference Book. Phoenix, AZ: Oryx Press

Rosenheck, R., Leda, C, Gallup, P., Astrachan, B., Milstein, R., Leaf, P., Thompson, D. & Errera P.
(1989). Initial Assessment Data from a 43-Site Program for Homeless Chronically Mentally 111
Veterans. Hospital and Community Psychiatry. 40: 937-942.

Ross, A., Royall, R. & Stine, O. (1989). Health and Mental Health Problems of Homeless Men and
Women in Baltimore. Journal of the American Medical Association, 262:10, 1352-1361.

Rossi, P. H. (1989). Down and Out in America: The Origins of Homelessness. Chicago, IL: The
University of Chicago Press.

Rossi, P. H. (1994). Troubling Families: Family Homelessness in America. American Behavioral
Scientist, 37: 342-395.

Roth, D. (1992). Homeless Veterans: Comparisons with Other Homeless Men. In M. J. Robertson, &
M. Greenblatt (Eds.) Homelessness: A National Perspective. New York, Plenum Press.

Roth, D., Toomey, B. G., & First, R. J. (1992). Gender, Racial, and Age Variations among Homeless
Persons. In M.J. Robertson & M. Greenblatt (Eds.), Homelessness: A National Perspective. New York:
Plenum Press, 199-211.

Rotheram-Borus, M. J., Koopman, C, & Ehrhardt, A. (1991). Homeless Youths and HIV Infection.
American Psychologist, 46: 1 188-1 197.

2-28 National Symposium on Homelessness Research

Special Populations of Homeless Americans

Rubin, D. H., Erickson, C. J., Agustin, M. S., Cleary, S. D., Allen, J. K. & Cohen, P. (1994). Cognitive
and Academic Functioning of Homeless Children Compared With Housed Children. Pediatrics, 93: 89-
294.

Schutt, R. (1986). A Short Report on Homeless Veterans — A Supplement to Homelessness in Boston in
1985: The View from Long Island. Boston, University of Massachusetts

Severo and Milford (1989). The Wages of War. New York: Touchstone

Shaffer, D., & Caton, C. L. M. (1984). Runaway and Homeless Youth in New York City: A Report to the
Ittleson Foundation. New York: Divisions of Child Psychiatry, New York State Psychiatric Institute and
Columbia University of Physicians and Surgeons.

Shinn, M. B., Weitzman, B. C. (1996). Homeless Families are Different. In Baumohl J. (Ed.).
Homelessness in America. Phoenix, Arizona: Oryx Press.

Shlay, A. B. (1993). Family Self-Sufficiency and Housing. Housing Policy Debate. 3: 457-491.

Simpson, G. A., & Fowler, M. G. (1994). Geographic Mobility and Children's Emotional/Behavioral
Adjustment and School Functioning. Pediatrics, 93: 303-309.

Skocpol, T. (1992). Protecting Soldiers and Mothers: The Political Origins of Social Policy in the
United States. Cambridge, Mass: Harvard University Press

Smith, E., & North, C. S. (1994). Not all Homeless Women Are Alike: Effects of Motherhood and the
Presence of Children. Community Mental Health Journal. 30: 601-610.

Snow, D. A, Baker, S. G, & Anderson, L. (1989). Criminality and Homeless Men: An Empirical
Assessment. Social Problems 36(5): 532-549.

Somerville, P. (1992). Homelessness and the Meaning of a Home: Rooflessness or Rootlessness?
International Journal of Urban and Regional Research. 16: 529-539.

Sosin, M. R. & Grossman, S. (1991). The Mental Health System and the Etiology of Homelessness: A
Comparison Study. Journal of Community Psychology 19: 337-350.

Steadman, H. L., Barbera, S. & Dennis, D. L. (1994). A National Survey of Jail Mental Health
Diversion Programs. Hospital and Community Psychiatry 45(1 1): 1 109-1 1 13.

Stoner, M. (1983). The Plight of Homeless Women. Social Service Review 57: 565-581, December.

Streuning, E. L. & Padgett, D.K. (1990). Physical Status, Substance Use and Abuse, and Mental
Disorders Among Homeless Adults. Journal of Social Issues 46(4): 65-81.

Streuning, E. L. & Rosenblatt, A. (1987). Characteristics of Homeless Veterans in the New York City
Shelter System. New York State Psychiatric Institute.

Suro, R. (1998). Strangers Among Us: How Latino Immigration is Transforming America. New York,
NY: Knopf.

National Symposium on Homelessness Research 2-29

Special Populations of Homeless Americans

Susser, E., Moore, R., & Link, B. (1993). Risk Factors for Homelessness. American Journal of
Epidemiology, 15: 546-556.

Susser, E., Struening, E. & Conover, S. (1989). Psychiatric Problems in Homeless Men. Archives of
General Psychiatry 46: 845-850.

Susser, E., Valencia, E., and Conover, S. (1993). Prevalence of HIV Infection Among Psychiatric
Patients in a New York City Men's Shelter. American Journal of Public Health 83(4): 568-570.

Tessler, R. & Dennis, D. (1989). A Synthesis of NIMH-Funded Research Concerning Persons Who are
Homeless and Mentally III. Washington, DC: U. S. Department of Health and Human Services.

Tilley, C. (1998). Durable Inequality. Berkeley and Los Angeles: CA, University of California Press.

Torres, R. A., Mani, S., Altholz, J. & Brickner, P. W. (1990). Human Immunodeficiency Virus
Infection Among Homeless Men in a New York City Shelter. Archives of Internal Medicine 150: 2030-
2036.

Torrey, E. F., Stieber, J., Ezekiel, J., Wolfe, S. M., Sharfstein, J., Noble, J. H. & Flynn, L. M. (1992).
Criminalizing the Seriously Mentally III: The Abuse of Jails as Mental Hospitals. Washington, DC:
Public Citizen's Health Research Group.

Tully, C.T., & Jacobson, S. (1994). The Homeless Elderly: America's Forgotten Population. Journal of
Gerontological Social Work, 33(314): 61-81.

Turner, M. A. & Reed, V. M. (1990). Housing America: Learning from the Past, Planning for the
Future. Washington, DC: The Urban Institute Press.

U. S. Conference of Mayors. (1987). The Continuing Growth of Hunger, Homelessness and Poverty in
America's Cities: 1987, A 26-City Survey. Washington, DC: Author.

U. S. Conference of Mayors. (1996). A Status Report of Hunger and Homelessness in America 's Cities.
Washington DC: Author.

U. S. Department of Housing and Urban Welfare. (1989). Report on the 1988 National Survey of
Shelters for the Homeless.

U. S. House of Representatives. (1984). Homeless Older Americans. Hearing Committee Publication
No. 98-461. 98th Congress, 2nd session. Washington, DC: U. S. Government Printing Office.

Vega, W. et al. (1998). Archives of General Psychiatry 55(8).

Weinreb, L. & Rossi, P. (1995). The American Homeless Family Shelter "system". Social Services
Review. 69: 87-107.

Weinreb, L., Goldberg, R., Bassuk, E., & Perloff, J. (in press). Determinants of Health and Service Use
Patterns in Homeless and Low-Income Housed Children. Pediatrics.

2-30 National Symposium on Homelessness Research

Special Populations of Homeless Americans

Weir, M., Orloff, A. S., Skocpol, T. (1988a) Understanding American Social Politics. In M. Weir, A. S.
Orloff & T. Skocpol (Eds.). The Politics of Social Policy in the United States. Princeton, NJ: Princeton
University Press.

Weir, M., Orloff, A. S., Skocpol, T. (1988b). The Future of Social Policy in the United States: Political
Constraints and Possibilities. In M. Weir, A. S. Orloff & T. Skocpol (Eds.). The Politics of Social Policy
in the United States. Princeton, NJ: Princeton University Press.

White, R. (1992). Its your Misfortune and None of My Own: A New History of the American West.
Norman, OK: University of Oklahoma Press

Wilensky, H. & Lebeaux, C. (1975). Industrial Society and Social Welfare. New York, NY; Free Press.

Wilson, W. J. (1987). The Truly Disadvantaged: The Inner City, The Underclass, and Public Policy.
Chicago, IL: University of Chicago Press.

Wilson, W. J. (1996). When Work Disappears: The World of the New Urban Poor. New York, NY:
Knopf.

Windle, M. (1989). Substance Use and Abuse Among Adolescent Runaways: A Four- Year Follow-Up
Study. Journal of Youth and Adolescence, 18: 331-344.

Wiseman, J. (1973). Stations of the Lost. Chicago, 111: University of Chicago Press.

Wood, D. L., Halfon, N., Scarlata, D., Newacheck, P., & Nessim, S. (1993). Impact of Family
Relocation on Children's Growth, Development, School Function, and Behavior. Journal of the
American Medical Association, 270(11): 1334-1338.

Wright, J. D. (1991). Poverty, Homelessness, Health, Nutrition, and Children. In Homeless Children
and Youth: A New American Dilemma, edited by Julee H. Kryder-Coe, Lester M. Salamon, & Janice M.
Molnar. New Brunswick, NJ: Transaction, 71-104.

Wright, J. D., & Weber, E. (1987). Homelessness and Health. New York: McGraw-Hill.

Yates, G. L., MacKenzie, R., Pennbridge, J., & Cohen, E. (1988). A Risk Profile Comparison of
Runaway and Non-Runaway Youth. American Journal of Public Health, 78: 820-821.

Ziesemer, C, Marcoux, L., & Marwell, B. E. (1994). Homeless Children: Are They Different From
Other Low-Income Children? National Association of Social Workers, 39(6): 658-668.

Zima, B.T ., Wells, K. B. & Freeman, H. E. (1994). Emotional and Behavioral Problems and Severe
Academic Delays Among Sheltered Homeless Children in Los Angeles County. American Journal of
Public Health, 84: 260-264.

National Symposium on Homelessness Research 2-31

Homeless Youth:
Research, Intervention, and Policy

Marjorie J. Robertson, Ph.D.

Paul A. Toro, Ph.D.

Abstract

Homelessness among youth in the U.S. is disturbingly common, with an estimated annual prevalence of
at least 5 percent for those ages 12 to 17. Although homeless youth appear throughout the nation, they
are most visible in major cities. Rigorous research on this special population is sparse, making it difficult
to capture an accurate and complete picture. Despite its limitations, recent research describes homeless
youth as a large and diverse group. Many homeless youth have multiple overlapping problems including
medical, substance abuse, and emotional and mental problems. Literature suggests that comprehensive
and tailored services are needed that address both the immediate and long-term needs of homeless youth.
Where appropriate, services should include assistance with meeting basic needs as perceived by youth as
a gateway to other needed services. In addition to serving those already homeless, interventions are
needed to prevent homelessness among at-risk youth.

Lessons for Practitioners, Policy Makers, and Researchers

• As used here, the term "homeless youth" focuses on minors who have experienced literal
homelessness on their own — i.e., who have spent at least one night either in a shelter or "on the
streets" without adult supervision. On occasion, where warranted by the research being discussed,
the term is also used to describe homeless young adults up to age 24.

• Homelessness among youth in the U.S. is disturbingly common. With an estimated annual
prevalence of at least 5 percent for those ages 12 to 17, adolescents appear to be at greater risk for
literal homelessness than adults. Although homeless youth appear throughout the nation, they are
most visible in major cities.

• Research on homeless youth has major limitations. Rigorous research on this special population is
sparse, making it difficult to capture an accurate and complete picture of homeless youth. Research
would benefit from studies that include large representative samples, reliable and valid measures,
comparison groups, and assessment of strengths as well as problems of homeless youth. Research
with this special population would likely benefit from more input by service providers, policy
makers, and the youth themselves.

• Despite limitations of the literature, it seems clear that homeless youth constitute a large and diverse
group

• Many youth have multiple overlapping problems. Many youth come from homes where family
conflict and child maltreatment are common. A wide range of health and behavior problems have
been documented among homeless youth, including substance abuse, emotional and mental
problems, and medical problems. While some of these problems appear to be long-standing, others
are probably exacerbated by the stressful experiences of homelessness. Homeless youth, especially

National Symposium on Homelessness Research 3-1

Homeless Youth: Research, Intervention, and Policy

those on the streets, sometimes resort to illegal activities such as prostitution or drug dealing in order

to survive. Many youth are victimized while homeless.

Few interventions with homeless youth have been formally evaluated. Careful program evaluation of

services is sorely needed, especially based on rigorous experimental designs.

The limited literature suggests that comprehensive and tailored services are needed that address the

immediate and long-term needs of homeless youth. Where appropriate, services should include

assistance with meeting basic needs as perceived by youth as a gateway to other needed services.

Other needed services include screening and treatment for health, mental health, and substance use

problems, reconciling family conflict, and educational or vocational training. In addition to serving

those already homeless, interventions designed to prevent homelessness among at-risk youth are

needed.

3-2 • National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Estimating Needs Based on Existing Research

Homelessness among young people in the United States and other nations is a serious and complex
problem. 1 The population of homeless youth seems to have disproportionately high rates of health
problems, emotional and behavioral problems, and substance use. Homelessness itself potentially poses
health risks to youth and can interrupt normal socialization and education, which likely affects a young
person's future ability to live independently. This paper provides a profile of homeless youth in the US,
documenting their diversity and their service needs. The paper then describes various intervention
approaches for homeless youth and discusses relevant social policy. It ends with recommendations for
future research.

Limitations of Existing Literature

The available literature on homeless adolescents has major limitations. Rigorous research on this special
population is sparse. Much research and other information about homeless youth is fugitive and often
dated. As a body of research, it is much less rigorous than contemporary research on homeless adults or
families. Information on homeless youth in large urban areas is most prevalent but may not generalize to
other areas, and different definitions and methods often prohibit meaningful comparisons. Cross-
sectional samples over represent longer-term homeless youth, which results in an over-reporting of
factors related to chronic homelessness. In addition, many studies lack rigorous sampling strategies,
which limits their generalizability.

Capturing a complete picture of homeless youth is difficult. In some cases, what is known about a
particular characteristic of homeless youth may be based on a single study. Where multiple studies are
available, findings may be contradictory.

Often contradictory findings occur because the results from a study depend very much on the source of
its sample. Recent literature has relied on four basic approaches to sampling. One surveys large groups
of teens in the general population and identifies youth from this pool who have a history of homelessness
(e.g., Ringwalt et al., 1998; Windle, 1989). These approaches under-represent youth who have longer
histories of homelessness or institutional histories. The second approach draws youth from shelters (e.g.,
McCaskill et al., 1998) who are often younger and less likely to have previous histories of homelessness.
The third draws a sample from clinical settings such as medical clinics (Yates et al., 1988). Such studies
describe youth seeking treatment and who are often very different from youth who do not seek treatment.
The fourth involves sampling from street locations where homeless youth are known to congregate (e.g.,
Cauce et al., 1994a; Kipke et al., 1995; Robertson, 1989). This street-sampling method, especially if it
includes youth who are 18 or older, generally yields a much more "deviant" profile of homeless youth.

Despite its limitations, recent literature suggests that homeless youth constitute a large and very diverse
population.

1 Though most of the research literature on homeless youth has been generated in the United States, there has been some
research conducted in other areas including Canada, Great Britain, and Australia, and Latin America. However, work reviewed
here draws exclusively on studies on homeless youth in the United States.

National Symposium on Homelessness Research 3-3

Homeless Youth: Research, Intervention, and Policy

Definitions

Defining what constitutes a "homeless youth" may seem fairly straightforward but, in fact, the issues
involved in the task are rather complicated. Most researchers studying homeless persons tend to focus on
persons who are "literally homeless" (Rossi, 1989). In this paper, we take a similar approach, using the
term "homeless youth" to refer primarily to minors on their own who have spent at least one night either
in emergency shelter or "on the streets" — that is, in places outdoors or in improvised shelter without
parental supervision. 2

An important decision to be made in defining "homeless youth" involves age. Across the existing
literature on homeless youth, the age range has varied widely. In this paper, we will generally use the
term "homeless youth" to refer to those between the ages of 12 and 17. However, many studies of
homeless youth have also included young adults up to age 24. We will still review studies of youth that
also include young adults, but we will note the extended age range involved. 3

The target population for this review is heterogeneous and includes youth described with a variety of
terms in research and popular literature (Kennedy et al., 1990; Robertson, 1996). These terms include
"runaways," who have left home without parental permission, "throwaways," who have been forced to
leave home by their parents, and "street youth," who have spent at least some time living on the streets.
All studies reviewed here include youth who have spent at least one night literally homeless, regardless
of the conditions of separation from their last home. It is important to note that some homeless youth
have experienced long or repeated episodes of homelessness, while others are having their first
experience with homelessness or have been homeless only for a few days.

To avoid the sort of terminological confusion common in the existing literature, throughout this paper we
will refer to this overall group as "homeless youth." However, when referring to specific reports or
studies, we may use the language of their authors specifically to identify the subgroup of homeless youth
they studied.

How Many Homeless Youth Are There?

The methodological problems in estimating the prevalence of homelessness have been widely discussed
and debated (Appelbaum, 1990; Blau, 1992; Burt, 1994, 1998; Culhane, Dejowski, Ibanez, Needham, &
Macchia, 1994; Foscarinis, 1991; Kondratas, 1991, 1994; Link, Susser, Strueve, Phelan, Moore &
Struening, 1994; Robertson, 1991; Rossi, 1989, 1994; Solarz, 1988; Toro & Warren, 1999; Wright,
Rubin, & Devine, 1998). Though most of this debate has involved homeless adults, many of the
controversies and methodological problems identified in the literature apply to homeless youth.

2 In our review, we exclude adolescents who are homeless with their parents.

To the extent that studies of homeless youth include persons who are 18 and over, the profile of homeless youth becomes more
similar to the profile for homeless adults. For recent overviews on the general characteristics of homeless adults, see Burt
(1998); Jahiel (1992); Robertson and Greenblatt, 1992; Shlay and Rossi (1992); Toro (1998); and Wright, Rubin, and Devine
(1998).

3-4 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Notwithstanding the debates, evidence suggests that the size of the homeless youth population is
substantial and widespread. 4 A recent large-scale survey of U.S. adolescents provides the most
comprehensive data to date on the extent of homelessness among youth (Ringwalt, Greene, Robertson,
and McPheeters, 1998). In 1992 and 1993, researchers interviewed a nationally representative household
survey of 6,496 youth, ages 12 to 17, as part of the National Health Interview Study (NHIS) sponsored by
the Centers for Disease Control and Prevention. To assess literal homelessness in the previous 12
months, youth were asked whether they had spent one or more nights in specific types of places. These
included: a youth or adult shelter; any of several locations not intended to be dwelling places (i.e., in a
public place such as a train or bus station or restaurant; in an abandoned building; outside in a park, on
the street, under a bridge, or on a rooftop; in a subway or other public place underground); or where their
safety would be compromised (i.e., with someone they did not know because they needed a place to
stay). Based on these estimates, researchers estimated the annual prevalence of literal homelessness
among this age group to be 7.6 percent (or 1.6 million youth in a given year). Even after revising their
estimate down, removing youth whose only experience with homelessness was in a "shelter" (a
potentially ambiguous term used in the interview), they still estimated that 5 percent had experienced
literal homelessness in the previous year (or more than 1 million youth in a given year). The prevalence
of homelessness did not vary significantly by family poverty status (determined by parent's reported
income), geographic area, or sociodemographic factors other than by gender (i.e., with significantly
higher rates of homelessness for males than females).

These estimates suggest that adolescents under age 18 may be at higher risk for homelessness than adults.
In 1990, researchers surveyed a nationally representative sample of 1507 adults in households with
telephones (Link, Susser, Stueve, Phelan, Moore, & Struening, 1994). To assess literal homelessness,
adults were asked if they had ever considered themselves to be homeless. Next they were asked if, while
homeless, they had ever slept in a shelter for homeless people or another temporary residence because
they did not have a place to stay, or in a park in an abandoned building, in the street, or in a train or bus
station. Among those who reported literal homelessness, those who had been homeless within the
previous five years were identified. Among US adults, five-year prevalence of self-reported
homelessness among those ever literally homeless was estimated at 3.1 percent (or 5.7 million adults in a
five-year period) and lifetime prevalence was estimated at 7.4 percent (or 13.5 million adults). Other
studies report similar lifetime rates (8%; Manrique & Toro, 1994).

Geographic Distribution and Patterns of Homelessness

Based on the national survey of housed youth described above, those with a history of recent
homelessness were found throughout the nation and across urban, suburban, and rural areas (Ringwalt et
al., 1998). Nevertheless, homeless youth appear to be most concentrated and visible in major cities (as is
the case for homeless adults and families). It is hard to determine whether this apparent concentration in
urban areas is a function of where researchers are located or a "true" over-representation of homeless
youth in urban areas.

4 For historical perspective, a 1983 report from the US Department of Health and Human Services estimated the prevalence of
runaway and homeless youth to be between 733,000 and 1.3 million per year, based on service-provider reports (Russell, 1998).
A study by the Justice Department (using telephone surveys of 10,367 households and 127 institutions in 1988 and early 1989)
estimated that 500,000 youth under age 18 become runaways or throwaways each year. State and local studies based on data
collected in the mid-1980s also suggested that the phenomenon was sizable and geographically widespread (for detail on such
estimates, see Chelimsky, 1982; Hemmens & Luecke, 1988; McClure & Dickman, 1988; Russell, 1998; Ryan, Goldstein, &
Bartelt, 1989; and Solarz, 1988).

National Symposium on Homelessness Research 3-5

Homeless Youth: Research, Intervention, and Policy

Street Youth. The research literature documents significant numbers of youth actually living "on the
streets" (i.e., not in shelters), primarily in certain large metropolitan areas on the east and west coasts.
While street youth have been studied in areas such as Los Angeles, San Francisco, Seattle, and New York
City, such youth have rarely been documented in Midwestern and southern communities. While street
youth represent an unknown proportion of all homeless youth, this subgroup is of obvious concern and
much research has focused on it. As we will document in this review, street youth generally show the
most disturbing histories of life disruptions and personal problems. This subgroup also often has longer
histories of homelessness and is less likely to use traditional services.

Local Residents. Contrary to popular stereotypes, several older studies show that most homeless youth
are in fact "local kids." For example, the majority (72%) of youths served in 17 runaway and homeless
youth programs nationally were from the immediate geographical area in which the program was located
(van Houten & Golembiewski, 1978). Most New York City shelter clients were born in the city
(Citizens' Committee for Children of New York, 1983; New York State Council on Children and
Families, 1984). In Albany, New York, the majority were from Albany or other parts of the Capital
District (58%); only about one-quarter were from out of state (Council of Community Services, 1984).
Service providers in Los Angeles County reported that the majority of their clients are from within the
county (67%) or within the state (18%; Rothman & David, 1985). Even in Hollywood, California, where
one might expect a more transient population, three-quarters of a sample of street youth had been
residents of the surrounding county for more than a year (Robertson, 1989). Although most homeless
youth seem to be local residents, many homeless youth (25-42%) are not local.

History of Homelessness. History of homelessness seems to vary by whether youth are sampled from
shelters or from the streets. Studies of homeless youth obtained from shelters generally find that most
homeless youth have been homeless for relatively short periods of time and have not experienced prior
homeless episodes. For example, in a probability sample of 118 adolescents (ages 12-17) from all six
major youth shelters in the Detroit metropolitan area, two-thirds had never been homeless before, and
most (86%) had been homeless for four weeks or less in their current episode (McCaskill, Toro, &
Wolfe, 1998). In contrast, in one Hollywood street sample (ages 13 to 17), most youth demonstrated
patterns of episodic (i.e., multiple episodes adding up to less than one year; 44%) or chronic
homelessness (i.e., being homeless for one year or longer; 39%) (Greenblatt & Robertson, 1993).

Characteristics of Homeless Youth

There is no typical homeless youth, and there is no single cause for youth homelessness. The literature
describes youth who experience homelessness and offers varied explanations for why youth become
homeless in the first place or why they may remain so. Yet, it is difficult to determine the degree to
which any particular characteristic or experience might be a primary cause or a contributing factor to
youth homelessness. Below, we review these findings and highlight the diversity of the homeless youth
population.

Background Characteristics

Gender and Age. In a national survey of youth (Ringwalt et al., 1998) males were significantly more
likely than females to report recent homelessness. In local studies of homeless youth, gender
representation seems to vary depending on the source and age of the sample (Robertson, 1996). Samples
from shelters suggest either even numbers or more females. In contrast, samples of street youth or older
youth tend to include more males.

3-6 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Based on recent studies, the vast majority of homeless youth appear to be age 13 or older, although
several studies have identified small numbers of youth homeless on their own who are as young as nine
(Clark & Robertson, 1996; Robertson, 1991).

Race or Ethnicity. A national survey of youth found no differences in rates of recent homelessness by
racial or ethnic group (Ringwalt, et al., 1998). While local studies tend to document that homeless youth
generally reflect the racial and ethnic make-up of their local areas, three local studies also report over-
representation of members of racial or ethnic minorities relative to the local community. For example,
African Americans were over represented in a probability sample from shelters throughout metropolitan
Detroit, where 46 percent of 1 1 8 homeless youth were African-American compared to 22 percent in the
area's general population (McCaskill et al., 1998). Both African Americans and Native Americans were
reported to be over-represented in a street sample from Seattle (N=229; ages 13-21; Cauce et al., 1994a)
and a statewide sample from Minnesota (N=165, ages 11-17; Owen et al., 1998).

Sexual Orientation. The rate of gay or bisexual orientation among homeless youth varies across studies.
In several studies with shelter and street samples, 3 to 10 percent of youth have reported their sexual
orientation as gay, lesbian or bisexual (Greenblatt & Robertson, 1993; Johnson, Aschkenasy, Herbers, &
Gillenwater, 1993; Rotheram-Borus et al., 1992b; Toro et al., 1998; Wolfe et al., 1994). Such rates
suggest that homeless youth are no more likely than non-homeless youth to report gay or bisexual
orientation when compared to the national rate of about 10 percent (Dempsey, 1994). However, higher
rates of gay or bisexual identity (16 to 38%) are reported in another set of studies. 5 The higher rates in
these studies (16 to 38%) can be accounted for by samples that came from street or clinical sites; tended
to be older; included more men (who generally have higher rates than women for gay or bisexual
orientation); or came from areas with significant concentrations of gay or bisexual persons in the larger
community.

Family Poverty and Youth Homelessness. Youth who experience literal homelessness seem to come
from less impoverished backgrounds than homeless adults. For example, sheltered youth came from
significantly better socioeconomic circumstances than the sheltered adults in Detroit (Bukowski & Toro,
1996). In a representative national sample of youth (ages 12 to 17), those living with families in poverty
were not more likely than other youth to have experienced homelessness in the previous year (Ringwalt
et al., 1998b). In contrast, among adults in a representative national sample, those with lower
socioeconomic status (SES) were more likely to experience homelessness in the previous five years (i.e.,
lower SES was defined by less than high school education; history of public assistance; or current annual
income of $20,000 or less) (Link et al., 1994).

Some state and local studies suggest that disproportionate numbers of homeless youth may come from
lower-income or working-class families and neighborhoods. For instance, for a broad four-state
Midwestern sample of 602 homeless youth, two-thirds of the youths' parents (68%) reported family
incomes under $35,000 (ages 12-22, obtained from shelters, street sites, and drop-in centers in urban,
rural and suburban areas) (Whitbeck et al., 1997b). In a Detroit shelter, most youth (69%) came from

5 Among patients of a medical clinic in Los Angeles (ages 10 to 24), 16 percent of runaways reported homosexual or bisexual
identity, compared to 8 percent of non-runaways (Yates, et al., 1988). In a study of homeless young men (ages 15 to 20) in a
Covenant House medical clinic in New York City, 25 percent reported being homosexual or bisexual (Stricof et al., 1991).
Similarly, in inner city Houston, one-quarter of homeless youth (ages 1 1-23) reported their sexual preference as homosexual or
bisexual (Busen & Beech, 1997). A rate of 38 percent (43% for young men and 27% for young women) was reported for a
Hollywood street sample that included youth who had been on the streets for two or more consecutive months as well as non-
homeless youth who were integrated into the "street economy" (72% of the sample was homeless; overall age ranged from 12 to
23; Kipke et al., 1995). Using similar sampling methods in Hollywood, this same research team found a 20 percent rate
(Albornoz, Montgomery, & Kipke, 1998; the age range was, again, 12 to 23).

National Symposium on Homelessness Research 3-7

Homeless Youth: Research, Intervention, and Policy

families in which the parents held unskilled or blue-collar jobs (McCaskill et al., 1998). Most youth also
(80%) came from neighborhoods where the median family income was under $40,000 (which was the
approximate 1990 median family income for the total Detroit metropolitan area). A more recent study in
Detroit, with a broader probability sample of 176 homeless youth (ages 13-17), obtained similar findings
(Toroetal., 1998). 6

The profile of homeless youth observed in the literature is highly dependent on the source of the sample
(as observed for homeless adults by Link and colleagues, 1994). Findings suggest that while family
poverty may not be related to homelessness among youth per se (given findings from the national
household survey), family poverty may be related to more chronic or repeated homelessness (given
recent local cross-sectional studies). Household surveys of formerly homeless youth may be more useful
for setting lower-bound estimates of the extent of homelessness among youth within a given period of
time. Such household surveys also likely present a more complete picture of the larger homeless youth
population and of factors that put a youth at risk for homelessness. However, because of their method,
they under-represent youth with longer histories of homelessness or institutional stays. On the other
hand, the profile of currently homeless youth from studies with cross-sectional samples is a "snap-shot"
of homeless youth on a given day, a population which likely over-represents youth with more chronic
histories of homelessness. Since they represent the potential service population, such cross-sectional
profiles may be more useful for assessing needs and service planning.

Family Conflict and Abuse. Youth consistently report family conflict as the primary reason for their
homelessness. Sources of conflict vary but include conflicts with parents over a youth's relationship with
a step-parent, sexual activity and sexual orientation, pregnancy, school problems, and alcohol and drug
use (Owen et al., 1998; Robertson, 1996; Toro, Goldstein, & Rowland, 1998; Whitbeck, Hoyt, Tyler,
Ackley, & Fields, 1997b).

Neglect and physical or sexual abuse in the home are also common experiences. Across studies of
homeless youth, rates of sexual abuse range from 17 to 35 percent, and physical abuse ranges from 40 to
60 percent (Busen & Beech, 1997; Robertson, 1989; Rothman & David, 1985). For example, most
(75%) of 122 sheltered homeless youth (ages 12-17) in Detroit reported some form of maltreatment
(Boesky, Toro, & Wright, 1995). Neglect was most common (57%), though many also reported physical
(40%) and sexual abuse (31%). Many experienced multiple forms of maltreatment as well (e.g., 16%
reported all three). When compared to housed peers, these homeless youth reported more maltreatment
and received higher scores on the standardized measures of family conflict (Wolfe, Toro, & McCaskill,
1999). Homeless youth reported that their parents were more physically and verbally aggressive toward
them, and that they were more verbally aggressive toward their parents. While violence from these youth
may very well have been in response to the parent's initial violence, violence in these families seemed to
occur in a context where both the youth and their parents may be engaging in violent or provocative
behavior and where escalation is a dangerous prospect.

There is evidence that neglect and abuse may actually precipitate separations of many youth from their
homes. In a Hollywood street sample (ages 13-17), many youth specifically reported leaving their homes
in the past because of physical abuse (37%) or sexual abuse (11%). One-fifth of the sample (20%) had at
some earlier point been removed from their homes by the authorities because of neglect or abuse
(Robertson, 1989). Similarly, a study of 356 street youth (ages 13-21) in Seattle found that 18 percent
had been removed from their homes (MacLean et al., 1999).

6 As demonstrated here, the profile of homeless youth depends very much on the source of the sample. The national household
survey of formerly homeless youth reveals a different profile than studies of currently homeless youth (Ringwalt, et al., 1998), as
has been observed for homeless adults (Link, et al., 1994).

3-8 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Families of Origin. Many homeless youth report disrupted family histories, which may contribute to the
risk for homelessness. In a Hollywood street sample (ages 13-17), many homeless youth never knew
their father (16%) or their mother (9%). Among the parents who were known, almost three-quarters had
been either divorced or never married (Greenblatt & Robertson, 1993). In a probability sample of 122
sheltered homeless youth from Detroit (ages 12-17), most grew up in single-parent (34%) or "blended"
(32%) families, many (22%) had been formally placed outside the home by officials, and about half
(48%) had lived with relatives (not parents) for a substantial amount of time (Reed, 1994).

Residential Instability. For many youth, homelessness appears to be part of a long pattern of residential
instability (Robertson, 1996). Consistently, homeless youth report repeated moves during their lifetimes.
For example, three quarters (73%) of a probability sample of 176 homeless youth in Detroit and
surrounding counties had experienced at least one move during the prior 12 months, and 55 percent had
move twice in this time period (ages 13-17; sampled from shelter, juvenile justice, and mental health
agencies) (Toro, 1998).

Many studies report that many homeless youth have repeated contacts with public social service systems,
many of which occurred at very early ages. Across several studies, rates of foster care placements have
ranged from 21 percent to 53 percent (Cauce, Paradise, Embry, Morgan, Lohr, Theofelis et al., 1997;
Owen et al., 1998; Robertson, 1989, 1991; Toro et al., 1998). Many homeless youth also report stays in
psychiatric facilities and criminal justice facilities. For example, one-quarter of a Hollywood street
sample (24%) reported previous psychiatric hospitalizations (Robertson, 1989). Majorities in two street
youth samples in San Francisco and Hollywood reported stays in juvenile detention facilities, and most
had multiple detentions (Clark & Robertson, 1996; Robertson, 1989).

Similarly, many adolescents in public systems have histories of homelessness or residential instability.
Adolescent psychiatric inpatients in Los Angeles were found to have histories of high residential
instability, with an average of 3 runaway episodes; most (70%) also had a history of placement into
foster care or with an alternative caregiver (Mundy, Robertson, Robertson, & Greenblatt, 1989). In
Albany County, New York, between 33 percent and 40 percent of jail inmates (ages 16 to 20), were
homeless (Council of Community Services, 1984).

Evidence from two studies suggests that youth in residential placements or in institutional settings risk
becoming homeless upon separation from those settings. In studies of street youth in Hollywood and San
Francisco, more than one-quarter of those who had been in foster care, group homes, or juvenile
detention became homeless upon their most recent separation. These youth reported that they had spent
their first night after leaving the respective sites either in a shelter or on the streets (Clark & Robertson,
1996; Robertson, 1989). (However, it is unclear whether these moves into homelessness were the result
of "running away" from the institutional placement or running away from the discharge site after leaving
the placement.)

Some providers suggest that youth who are returned inappropriately to their prior homes due to lack of
more appropriate alternative long-term placements may also be at risk. A 1985 Boston report suggested
that the lack of available out-of-home resources (e.g., foster and group homes) is often more influential in
service planning than the needs of the adolescents and their families. Half of the cases of first-time, out-
of-home placements in one setting were returned home despite the assessment of the emergency shelter
staff that this was an inappropriate placement decision (Greater Boston Emergency Network, 1985).

National Symposium on Homelessness Research 3-9

Homeless Youth: Research, Intervention, and Policy

Additionally, some youth "age out" of the foster-care system with limited alternatives in place. One
recent follow-up of such youth found that, in the 12 months after "aging out," a full 12 percent of the
youth had spent at least some time homeless (Courtney, Piliavin, Grogan-Kaylor, & Nesmith, 1998).

According to an older survey of providers, less than half (47%) of youth in Los Angeles shelters were
considered to have a realistic prospect of returning to their homes (Rothman & David, 1985). Only 19
percent were good candidates for immediate family reunification; and 25 percent were chronic runaways
who were very unlikely to be returned home or to placement. In contrast to these findings, the majority
of youth in federally funded shelters nationally (57%) were reunited with families or placed in a safe
living environment (National Network of Runaway and Youth Services Inc., 1985).

School and Learning Difficulties. Consistently, studies suggest that many homeless youth have had
interrupted or difficult school histories, and many are currently not attending school. In several studies,
25 to 35 percent of youth report being held back a year in school (Clark & Robertson, 1996; Robertson,
1989; Upshur, 1986; Young, Godfrey, Matthew, & Adams, 1983). In two studies of street youth, about
one-quarter report participation in special or remedial classes (Clark & Robertson, 1996; Robertson,
1989). In a Detroit sample of 176 homeless youth, 85 percent had at some point been suspended from
school, 26 percent had been expelled, and 15 percent had dropped out of school (Toro et al., 1998). One
study found a high rate (28%) of attention deficit disorder (Cauce et al., 1997). While a history of
school problems is prominent in the literature, its contribution to homelessness is unclear. School
problems are often hypothesized to be a precipitant of family conflict that results in a runaway response.
Others suggest that school difficulties are merely symptoms of more pervasive family problems.

Emotional and Mental Problems

Mental Disorders. As for homeless adults, the assessment of mental health status among homeless
adolescents poses a number of problems (Robertson, 1992; Toro, 1998). It is difficult to determine
whether a homeless youth's emotional disturbance at a given point in time is more causally associated
with an underlying emotional or mental disorder, the exigencies of homelessness; chronic stresses such
as family violence or parental substance abuse; the youth's own use of alcohol or other drugs; or
combinations of these (Robertson, 1996).

In any event, several studies have documented high rates of emotional and mental health problems among
homeless youth. Rates of serious disorders assessed with standardized instruments with diagnostic
criteria range from 19 to 50 percent. For example, half of a sample of 150 youth from a New York City
shelter (50%) had at least one major affective disorder as assessed by the DISC (Feitel et al., 1992).
Among street youth in Hollywood (ages 13-17), 26 percent met DSM-III criteria for major depression
compared to 4-9 percent of community and school samples of adolescents (Russell, 1996). In addition,
many youth reported serious psychotic symptoms (Mundy, Robertson, Greenblatt, & Robertson, 1989).
In another street sample (ages 13-21), 45 percent of the youth received at least one DSM-III-R diagnosis
for a mental disorder (Cauce et al., 1997). These disorders included depression (19%), dysthymia (14%),
mania (13%), hypomania (9%), and psychosis (9%). In two different probability samples from
throughout metropolitan Detroit (one from shelters only, N=122; the other from a variety of sites,
including shelters, juvenile justice facilities, and mental health centers, N=180), similar rates for these
same mental disorders were obtained (McCaskill et al., 1998; Toro et al., 1998).

It should be noted that in a rare study that included a carefully-matched comparison group of housed
youth, McCaskill and colleagues found that the rates for many mental disorders were not significantly
different, although homeless youth did have significantly higher rates of disruptive behavior disorders

3-10 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

and alcohol abuse or dependence. Such findings highlight the need for appropriate comparison groups
when attempting to identify distinctive characteristics of homeless youth.

As in the adult homeless population, the co-occurrence of substance abuse disorders and serious mental
health problems has also been documented in several studies (Robertson, 1989; Rotheram-Borus, 1993;
Russell, 1998; Shaffer & Caton, 1984; Upshur, 1986; Yates, MacKenzie, Pennbridge, & Cohen, 1988).

In San Francisco, two-thirds of a street sample met DSM-III-R diagnostic criteria for post-traumatic
stress disorder (PTSD) (Clark & Robertson, 1996). Almost half of the sample (46%) had experienced
PTSD symptoms related to their disorders within the previous two weeks. Most frequently reported
traumatic events included seeing another person hurt or killed or being physically or sexually assaulted
themselves.

Suicide Attempts. Studies of homeless youth consistently report suicide attempt rates that are higher
than rates for normative groups. In a study of homeless youth in New York City shelters, more than one-
third (37%) had ever attempted suicide, and one-third of these had made repeated attempts (Rotheram-
Borus, 1993). Many in the sample (16%) reported suicide attempts in the previous month. Nearly one-
quarter (24%) of runaways in New York City shelters (Shaffer and Caton, 1984) and 18 percent of
runaways using an outpatient health clinic in Los Angeles (Yates et al., 1988) reported suicide attempts.
About half (48%) of a Hollywood street sample (age 13-17) had attempted suicide, and more than half of
these had repeated attempts. More than one-quarter of the sample (27%) had attempted suicide during
the previous 12 months (Robertson, 1989). Other studies have reported equally high rates (Ackley &
Hoyt, 1997; Feitel et al., 1992; Powers, Eckenrode, & Jaklitsch, 1990). All reported rates of suicide
attempts for homeless youth are higher than the lifetime rate for adults reported in the LA ECA project
which was 4 percent (Russell, 1998).

Conduct Problems. A wide range of conduct problems are reported for homeless youth. Though it
appears that many such problems are of long duration, some may develop or become exacerbated by
experiences while homeless. In three studies of homeless youth, rates of conduct disorder ranged from
48 percent to 93 percent (Cauce et al., 1997; Feitel, Margetson, Chama, & Lipman, 1992; Robertson,
1989) using the Diagnostic Interview Schedule for Children (DISC) (Fisher, Wicks, Shaffer, Piacentini,
& Lapkin, 1992). It is important to note that current diagnostic criteria, in fact, consider the experience
of running away or being homeless, itself, as a key sign of conduct disorder. However, even excluding
such criteria, the rate of conduct disorder among homeless youth is high. For instance, in a study of
sheltered youth (ages 12-17) that used the DISC but excluded such criteria, the rate of disruptive
behavior disorders (primarily conduct disorder) was still high (39%) and significantly greater than that in
a matched housed sample (20%) (McCaskill et al., 1998).

Research suggests that homeless youth may have associations with deviant peers, some of whom may
themselves be homeless. Gang activity appears common among homeless youth. Across several studies
on homeless youth, a history of gang participation has ranged from 14 percent to 53 percent (Kipke,
O'Conner, Palmer, & MacKenzie, 1995; Robertson, 1989; Toro et al., 1998; Whitbeck et al., 1997a).

National Symposium on Homelessness Research 3-1 1

Homeless Youth: Research, Intervention, and Policy

Substance Use and Abuse

Youth Substance Use. Though it is not possible to determine from existing research the extent to which
alcohol or other drug use may contribute to youth homelessness, many youth report substance use
themselves and by their parents. Based on DSM-III criteria, most youth in a Hollywood street sample
(ages 13-17) met diagnostic criteria for substance use disorders [i.e., alcohol disorders (48%), other drug
disorders (39%), or both (26%)] (Robertson, 1989; Robertson, Koegel, & Ferguson, 1989; Russell,
1998). About one-quarter (26%) reported a history of injection drug use (IDU). The majority used illicit
drugs before they experienced homelessness the first time (74.7%), and several reported that their own
drug use had contributed to their leaving home (17.7%).

In a study of clients of a Hollywood outpatient clinic (ages 12-24), recent alcohol and other drug use was
significantly higher among homeless compared to non-homeless youth using the same clinic (48% vs.
19%, respectively). Many reported IDU (8% compared to 0.1% of non-homeless clients) (Kipke,
Montgomery, & MacKenzie, 1993). About half of youth in New York City shelters (ages 11-19)
reported physical symptoms of substance abuse, and 17 percent reported addiction symptoms (Koopman,
Rosario, and Rotheram-Borus, 1994). In a probability sample of sheltered homeless youth, 21 percent
met DSM-III-R criteria for alcohol abuse or dependence and 24 percent for drug abuse or dependence
(McCaskill et al., 1998).

Rates of substance use seem to vary dramatically by history of homelessness. In three large national
samples, street youth showed the highest rates of substance use followed by sheltered youth and
runaways and finally housed youth (Greene, Ennett, & Ringwalt, 1997). Comparing youth who reported
having run away once, two or more times, or never, Windle (1989) found a similar pattern, with those
having multiple homeless episodes showing the highest rates of substance use or abuse.

As with the general population, rates of substance use and abuse increase with age. Among homeless
clients of a community-based clinic in Hollywood, older youth were significantly more likely to report
use of alcohol, stimulants, narcotics, and injection drug use (Kipke, 1995). Among a probability sample
of 122 youth in shelters in metropolitan Detroit (ages 12-17), older youth had significantly higher rates of
DSM-III-R diagnoses of drug abuse or dependence (Boesky et al., 1997). However, rates for the youth
overall were significantly lower than homeless adults from shelters in the same city (Bukowski & Toro,
1996).

Parental Substance Use. One study suggests that parental alcohol use may contribute to youth
homelessness. In a Hollywood street sample, 24 percent of the youth (ages 13-17) reported that they had
"run away or left home" at least once because their parent or step-parent had an alcohol problem which
caused frequent arguments or physical violence (Robertson, 1989). Other studies suggest high substance
use by parent. For example, a study of intake records for over 44,000 youth in federally-supported
shelters reported that drug abuse by the parent figure was the principal problem of 16 percent to 18
percent of youth (U.S. Government Accounting Office, 1989). For youth in 17 shelters across the nation,
parental alcohol abuse was correlated significantly with runaway behavior (van Houten & Golembiewski,
1978). Miller, Hoffman, and Duggan (1980) found that 41 percent of runaways reported that one or both
of their parents had a problem with alcohol and 17 percent reported that one or both parents had a serious
drug problem. Toro et al. (1998) found that 44 percent of homeless youth reported that one or both of
their parents had at some point received treatment for alcohol, drug, or psychological problems.

Health Status. Like homeless adults, homeless youth appear to be at greater risk than their domiciled
counterparts for a variety of medical problems, and their health often deteriorates while homeless. Youth

3-12 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

on the streets in particular often sleep too little, and when they do, it is often in an unsafe, unclean, or
overcrowded environment (Clark & Robertson, 1996). They may have little money and eat poorly. They
may have little opportunity to maintain adequate personal hygiene and are hard put to find the time or
place to recuperate adequately from illness or injury. They suffer disproportionately from traumatic
injury, skin infestations, infectious diseases, nutritional disorders, and other conditions (Kennedy et al.,
1990; Yates et al., 1988). Because of the patient mix and the concentration of health problems that are
less common in conventional medical practices, a specialization of sorts in "street medicine" has
developed among health professionals who treat homeless youth, (Kennedy et al., 1990).

Sexual Behavior. The literature reveals high rates of sexual activity among homeless youth, but variable
rates of protection against pregnancy or sexually transmitted diseases. Studies consistently report that
the majority of youth (i.e., from 62% to 93%) are sexually active (i.e., had sex at least once). For
example, in New York City shelters, most males (93%; ages 12 to 17) were sexually active (Rotheram-
Borus, Meyer-Bahlburg, Koopman, Rosario, Exner, Henderson et al., 1992a; 1992b). Similarly, 92
percent a Hollywood street sample (ages 13 to 17) were sexually active. While most of these (82%)
reported using birth control the last time they had sex, only about half reported condom use (Robertson,
1989). In another study of Hollywood street youth (ages 12-23), most (70%) reported recent (30 day)
sexual activity (Kipke et al., 1995). In a sample of 602 homeless youth from 4 Midwestern states,
Whitbeck et al. (1997b) found that most youth had intercourse prior to age 16 (70% of the males and
85% of the females, ages 12 to 22). Among those reporting intercourse in the past year, only one-third
(36%) reported always using condoms. In Detroit, Wolfe, Levit, and Toro (1994) found that 71 percent
of homeless youth (age 12 to 17) in shelters had ever had intercourse and 43 percent reported being
currently sexually active. In another Detroit study, Toro et al. (1998) found that 62 percent of 176
homeless youth (age 13 to 17) reported ever having had vaginal, anal, or oral sex. Both studies also
found that, compared to matched housed youth, the homeless youth were significantly more sexually
active.

Pregnancy. In four local studies, the lifetime rate of pregnancy for homeless girls has ranged from 27 to
44 percent, and 6 to 22 percent have reported having given birth (Cauce, Morgan, Wagner, Moore, Sy,
Wurzbacher et al., 1994a; Owen et al., 1998; Robertson, 1989; Toro et al., 1998; Whitbeck et al., 1997b).
Studies have identified as many as 10 to 20 percent of homeless young women who are currently
pregnant (e.g., Toro et al., 1998; Robertson, 1996). Young women who are pregnant while homeless are
at risk for low-birthweight babies and high infant-mortality because they are unlikely to get prenatal care
and may not have adequate health and dietary habits (Kennedy et al., 1990; Sullivan & Damrosch, 1987).

Risk for HIV and AIDS. Homeless youth present a high-risk profile for human immunodeficiency virus
(HIV) infection. Specific high-risk sexual and drug use behaviors including multiple sex partners, high-
risk sexual partners, survival sex, minimal condom use, injection drug use, sharing needles, and having
sex while high (Allen, Lehman, Green, Lindergren, Onorato, Forrester, Field Services Branch, 1994;
Kipke et al., 1995; Greenblatt & Robertson, 1993; Rosenthal, Moore, & Buswell, 1994; Rotheram-Borus,
1991, 1992a, 1992b; Toro et al., 1998). Risk behaviors for HIV exposure are more common among
youth who are older, homeless longer, and not staying in shelters. Despite knowledge about transmission
modes, many homeless youth do not use protection against exposure.

Recent seroprevalence studies in clinical samples suggest that HIV is already a widespread health
problem among homeless youth and young adults in some areas. In one study of HIV rates in clinical
samples of homeless youth ages 15 to 24, the rate of HIV-positives across four cities was 2 percent.
Rates were higher among youth over age 19, and they varied dramatically by site. These included Dallas
(0%), Houston (1%), New York City (4%), and two sites in San Francisco (2% and 7%) (Allen et al.,

National Symposium on Homelessness Research 3-13

Homeless Youth: Research, Intervention, and Policy

1994). Similarly, in a medical clinic in Covenant House in New York City, 6 percent of "street kids"
overall tested HIV-positive (6% of young men and 5% of young women; Kennedy et al., 1990).
Covenant House health clinics also produced elevated rates in New Orleans (3%), Fort Lauderdale (3%)
and Houston (2%). Because these communities have higher rates of HIV infection generally, the high
rates of HIV in New York or San Francisco may not generalize to other areas. Yet the risk of exposure
poses a real threat to homeless youth across geographic areas who report high-risk behaviors.

Survival While Homeless

Shelter, Food, and Other Basics Needs

Many youth have difficulty meeting basic needs. For example, in a San Francisco street sample (ages 15
to 19), most youth reported that they had spent the previous 30 nights outside, in abandoned buildings (or
"squats"), traveling, and in public places such as doorways, allies, parks, beaches, and under bridges.
Very few had stayed even one night in a shelter (15%). Several reported institutional stays including one
young woman who had been in a hospital for childbirth. One youth reported spending three nights in a
dumpster (Clark & Robertson, 1996). In this same study, youth who slept in public spaces often formed
groups in which individuals took turns staying awake to keep guard. A few reported committing offenses
that resulted in arrest in order to secure "shelter" for the night (Clark & Robertson, 1996). Providers
occasionally report that minors sometimes misrepresent their age to gain access to adult shelters.

In a study of Hollywood street youth (ages 13-17), most (79%) identified "improvised shelter" as their
usual sleeping place. This included abandoned buildings, vehicles, parks and beaches, loading docks,
rooftops, and crawl spaces under houses. Relatively few in the sample had used shelters recently (15%)
due largely to the scarcity of shelter beds in the area (i.e., at the time, 50 youth shelter beds throughout
Los Angeles County) (Robertson, 1989; Greenblatt & Robertson, 1993). Shelters or meal programs were
the most usual sources of food. Yet about half of the youth (48%) reported difficulty getting adequate
food, and the majority (57%) had spent at least one day in the past month with nothing to eat. Many also
reported difficulty finding a place to clean up, to obtain medical care, or to find clothing (Greenblatt &
Robertson, 1993; Robertson, 1989). Youth reported little if any income, most of which came from legal
sources such as odd jobs or family gifts. However, income from illegal activities was also common
including sex work and drug dealing (Robertson, 1989).

Anecdotal reports from staff and youth suggest that staff at shelters and other sites sometimes exclude
youth with severe emotional problems, those dangerous to themselves or others, those with alcohol or
drug problems, or those with HIV infection.

Resorting to Illegal Activities

Many homeless adolescents report illegal behavior. However, some of this behavior may be part of their
strategies for survival. Some illegal behaviors may provide for basic needs directly (for example,
breaking into an abandoned building for a place to stay or trading sex for food or shelter) while others
may generate income to meet basic needs (for example, selling drugs or sex). In a 4-state Midwestern
sample of 602 homeless youth, 23 percent reported stealing, 14 percent forced entry to a residence, 20
percent dealt drugs, and 2 percent engaged in prostitution (Whitbeck et al., 1997b). In an unusual sample
of 409 Los Angeles street youth (ages 12-23), which included many who were not literally homeless but
who were "integrated" into the street economy, 43 percent of the sample (46% of young men and 32% of
young women) reported ever engaging in survival sex, which included trading sex for food, a place to

3-14 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

stay, drugs, or money (Kipke et al., 1995). Of these, 82 percent traded sex for money, 48 percent for
food or a place to stay, and 22 percent for drugs. Almost one-quarter of the sample (22%) reported
survival sex in the previous 30 days. Similarly, among clients of a Hollywood health clinic, 26 percent of
runaway clients reported involvement in "survival sex" compared to only 0.2 percent among non-
runaway clients (Yates et al., 1988). Similarly, about one-third of a Hollywood street sample (ages 13-
17) reported ever trading sex for money, food, or shelter. Most of these (75%) reported doing so only
when homeless. Sex also had been traded for drugs by 11 percent of the sample. About half of the
sample had ever sold drugs (52%), although many reported doing so only when homeless (21%).
Although generating cash income was the principal motive for drug sales, one-fifth of the sample also
sold drugs to support their own drug use.

Victimization

Studies have reported high rates of victimization among homeless youth. Runaway clients of an
outpatient clinic in Hollywood sought treatment for trauma (4%) and rape (2%) at rates which were two
and one-half and three times higher than non-runaway clients (Yates et al., 1988). The majority of a
Hollywood street sample had been victimized in the past twelve months, including high rates of physical
assault (42%) and sexual assault (13%; Greenblatt & Robertson, 1993). In their 4-state Midwestern
sample, Whitbeck et al. (1997b) documented a wide range of types of victimization. While homeless, 18
percent of the boys and 12 percent of the girls had been beaten up more than once, 11 percent and 7
percent had been robbed more than once, and 1 1 percent and 4 percent had been assaulted with a weapon
more than once. These researchers have also found evidence for a "risk-amplification" model for
understanding adolescent homelessness (see Ackley & Hoyt, 1997; Whitbeck, Hoyt, & Ackley, 1997a;
Whitbeck & Simons, 1990). This model proposes that a variety of background characteristics, including
maltreatment, poverty, parental psychopathology, and negative parenting, all put homeless youth at risk
for poor outcomes. Homelessness also puts the youth in a context conducive to further negative
outcomes (e.g., through experiences on the street and with deviant peers), which amplifies the impact of
the background characteristics. In some recent and disturbing findings based on a 5-month follow-up of
354 street youth from Seattle, Hoyt and Ryan (1997) found that those with a prior history of victimization
were the most likely to be victimized during the follow-up period.

Long-Term Outcomes

Will These Youth Become Homeless Adults?

Since the mid-1970s, scholars and service providers have expressed concern that homeless youth would
become a new generation of homeless adults (Blumberg, Shipley, & Barsky, 1978; Miller, 1991). There
is no longitudinal evidence that homeless youth are, in fact, at heightened risk for homelessness later in
adulthood (although a few ongoing studies are investigating this; Cauce et al., 1994b; Toro et al., 1998).
Nevertheless, recent evidence does indicate that 9 percent to 26 percent of homeless adults were first
homeless as children or youth (Susser, Streuning, & Conover, 1987; McChesney, 1987; Zlotnick et al., in
press). These rates are higher for homeless adults than adults in the general population among whom
about 7 percent have ever experienced homelessness (Link et al., 1994; Manrique & Toro, 1995).

Other Long-term Outcomes

In a 30-year follow-up of clients from a child guidance clinic, Robins and O'Neal (1959) found that
runaways had higher rates of mental disorder, divorce, and arrest than non-runaways. Olson et al. (1980)
obtained similar results in a 12-year follow-up of 96 runaways from the Washington, DC area. Those

National Symposium on Homelessness Research 3-15

Homeless Youth: Research, Intervention, and Policy

who had ran away more than once, as compared to their siblings or those who ran away only once, had
poorer work histories, more involvement with the justice system, and were more likely to be single.
More recently, Windle (1989) used the National Longitudinal Survey of Youth to compare 14-15 year
olds who had never run away (n=l,139) to those who had run away once (n=61) or more times (n=41).
After four years, he found that the repeat runaways reported more alcohol and drug use and abuse, more
delinquent behaviors, lower self-esteem, and a higher rate of dropping out of school, while the one-time
runaways fell about midway between the never and repeat runaways on most of these domains.

Intervention Strategies

Strategies are needed to reduce the amount of harm a youth encounters while homeless. In the short
term, emergency and transitional services are needed for those who are currently homeless. Providers
suggest that the younger youth and those in their first episode of homelessness are more likely to
reconcile with families if the homeless episode is responded to with early intervention.

For the longer term, however, strategies are also needed to reduce the number of youth who become
homeless. Homelessness itself presents physical and mental health risks to the youth. It may also
represent an interruption of normative socialization and education, which will likely affect the ability to
live independently in the future.

Providing Needed Services to Homeless Youth

There is little comprehensive information on model programs serving youth or young adults who are
homeless or at risk of homelessness.

Comprehensive and Tailored Services

Homeless youth and young adults face many barriers to services in the larger community (Clark and
Robertson, 1996). Most are survivors of difficult situations, and many are skeptical and distrustful
toward adults. Many street youth in particular have become accustomed to taking care of themselves and
some seem unwilling to come into service sites or eventually return to a family or foster home in which
they could lose a great deal of control over their everyday lives. Many homeless youth have serious
emotional or mental problems. In addition, interventions may have to take place in the context the
youth's substance use and behavior problems. While many youth report only occasional drug or alcohol
use, others cycle in and out of more hard core drug use, complicating any intervention effort (Clark &
Robertson, 1996). In many cases providers first may want to help homeless youth meet their immediate
needs. Basic services can then provide a gateway to other needed services.

Providers have suggested that since homeless youth have diverse needs which cross agency jurisdictions,
they require a comprehensive service array (New York State Council, 1984). Homeless youth need many
services, including housing, education, vocational training, health care, mental health care, substance
abuse services, and legal assistance. Coordination among providers is needed to strengthen their ability
to serve the population. Interagency cooperation could be augmented by linkages with community non-
profit agencies serving youth. Bringing together stakeholders from all parts of the youth-care community
can help build the needed continuum of care for homeless youth by consolidating resources and to
forging service alliances (Mangano, 1999).

3-16 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Based on similar interventions designed for persons with mental disorders (Morse, Calsyn, Allen,
Tempelhoff, & Smith, 1992; Toro, Passero Rabideau, Bellavia, Baeschler, Wall et al., 1997), Cauce and
colleagues (1993, 1994a, 1997) have developed a comprehensive approach to case management for street
youth ages 13-21. The approach involves many components including careful assessment and treatment
planning, linkage to a full range of needed community services, crisis counseling, flexible use of funds to
support youth, small caseloads (no more than 12 cases per counselor), and open-ended service provision.
Preliminary findings have suggested some modest positive gains over a 3-month follow-up period for the
program youth in comparison to other street youth randomly assigned to "regular case management"
(Cauce etal., 1994a).

Special Populations with Special Needs

There are many different groups among homeless youth with special needs. These include gay and
bisexual youth; non-English speakers; those who have been homeless longer; those involved in sex work;
pregnant teens; and youth with serious medical, emotional, behavioral, or substance use problems. Staff
of shelters, drop-in centers, medical clinics and other programs might better be trained to deal with the
particular circumstances, experiences, and special needs of such groups (Rotheram-Borus, 1991b; 1993).
Young adults (e.g., ages 18 to 24) are another special group that often falls through the cracks between
public systems of care because they are ineligible for treatment in children's service systems at the same
time that the their developmental needs may not be met by adult service systems.

Shelters as Interventions Sites

Besides providing a safe place to spend the night, youth shelters have often served as sites from which to
mount special programs and therapeutic interventions (Rotheram-Borus, 1991b). However, some
homeless youth and young adults never use shelters or use them only intermittently (Kipke et al., 1995;
Robertson, 1996). Shelters sometimes exclude youth most in need of intervention because they lack
adequate staff or appropriate facilities to deal with youth who have special needs. According to
anecdotal reports, youth most likely to be excluded from shelters are those who pose a threat to
institutional routine or safety (i.e., those who are actively psychotic, suicidal, or intoxicated; or those
with HIV or other infectious diseases). At times, appropriate or accessible shelter beds for youth are not
available. In addition, many youth may choose not to use shelters because there are too many demands
on their behavior or the programs are too structured (Chelimsky, 1982; Clark & Robertson, 1996;
Rotheram-Borus, 1991b; Rothman & David, 1985). To reach such youth, services can be provided in
sites other than shelters. Educational and treatment interventions have been located successfully within
low-demand community sites such as drop-in centers as well as through outreach programs to youth on
the streets.

Treatment Services

A number of studies have documented high need for treatment but low utilization of formal treatment
programs for medical, mental, and substance use services (Farrow, Deisher, Brown, Kulig, & Kipke,
1992; Kennedy, 1991; Johnson, Aschkenasy, Herbers, & Gillenwater, 1993; Morey & Friedman, 1993;
Robertson, Koegel, & Ferguson, 1989). In most states, minors may consent to some types of health care
including treatment for alcohol, drug or mental health problems, true emergencies, or treatment for
sexually transmitted diseases (Kennedy et al., 1990). Even so, few homeless youth have adequate
contact with the health care system, which may result in delayed treatment for acute and chronic health
problems.

National Symposium on Homelessness Research 3-17

Homeless Youth: Research, Intervention, and Policy

Providers have identified specific barriers to treatment in formal settings. These include the youth's
mistrust of health professionals, the lack of social skills to cooperate in their own care, failure to keep
appointments for follow-up care, failure to follow-through in treatment once immediate distress has been
relieved, and problems in transferring care when a youth gets moved to a different neighborhood
(Kennedy et al., 1990). Aggressive screening of homeless youth can identify such health problems as a
first step in providing proper treatment and health care. In designing treatment services, many of which
have been developed for adults, it will be important to adapt the services to the specific needs of
homeless youth and young adults.

Researchers have recommend that homeless youth and young adults be targeted for health education and
prevention programs, given their high risk for exposure to and transmission of HIV, other STDs, and
other infectious diseases (Rotheram-Borus, 1991a). Studies suggest that accessible HlV-testing services
will be used by homeless youth (Greenblatt & Robertson, 1993). Because of high rates of prior suicide
attempts, current ideation, plans for suicide, and depression, staff working with homeless youth should
receive training in assessing suicidality (Rotheram-Borus, 1993).

Education and Job Training Opportunities

Once homeless on their own, homeless youth face extraordinary economic problems. Homeless youth
and young adults often need to become part of the work force. Unfortunately, most are ill prepared for
work, requiring extensive job training and placement services. Vocational and occupational programs
are a fundamental part of the transition from the streets to mainstream society. Providers recommend
programs that enable these young people to complete high school, college, or some alternative education,
and to develop marketable skills (Morey & Friedman, 1993; National Network of Runaway and Youth
Services, Inc., 1985).

Interventions to Prevent Homelessness

Though there has been considerable discussion in the literature on services for youth who are already
homeless, little attention has been given to how we might prevent homelessness in the first place. Below,
we consider two basic approaches to accomplishing prevention of homelessness among youth.

Preventing Repeated Homelessness. For youth and young adults who have already experienced
homelessness, an obvious goal of services should be to prevent any future homeless episodes. Such
interventions could target youth early in their "homeless careers" (e.g., youth with a single short
experience with homelessness or little or no time spent on the streets). Toro and Bukowski (1995) have
recently advocated for an expanded service delivery model for youth shelters. This model would
supplement the crisis intervention approach common in most youth shelters to provide a variety of long-
term services for youth and their families. Many have recognized this need and have proposed intensive
case management programs (e.g., Cauce et al., 1993), "full-service" shelters (e.g., Rotheram-Borus,
1991), transitional living programs for those who cannot be reunited with their families (MacAllum et al.,
1997), and other ongoing services for youth after their brief stays in a shelter. Service providers often
would like to offer such expanded services, but have limited resources to do so (Sedlak, Schultz, Wiener,
& Cohen, 1997). Since most homeless youth eventually return to their families, providers might consider
active outreach to all family members in addition to the youth themselves to help the families cope and
remain intact.

3-18 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Primary Prevention. Primary preventive interventions would attempt to prevent homelessness and other
harmful outcomes among adolescents in the general population. Such interventions are generally
consistent with a youth development approach to improving the lives of youth (Family & Youth Services
Bureau, 1996) and have proven effective in dealing with a wide range of problems in children and youth
(Durlak & Wells, 1997; Price, Cowen, Lorion, & Ramos-McKay, 1988). In the case of homelessness,
interventi6ns could identify youth at risk for residential instability and homelessness or could be targeted
even more broadly. Based on research findings, there appear to be a number of risk factors for both
youth and adult homelessness. These include socioeconomic status, problematic family environments
(including family violence and substance abuse), and a history of conduct problems and delinquency.
Implementation of family-based preventive interventions would be one useful approach. School-based
interventions might also be effective at preventing homelessness and other harmful outcomes. Peer
groups have been utilized in a number of existing effective prevention programs (e.g., Pedro-Carroll,
Cowen, Hightower, & Guare, 1986) and could be useful in programs to prevent homelessness. Child-
protective services in many localities, with often-limited resources, frequently seem to focus primarily on
the removal of youth from abusive homes and the prosecution of abusive parents. Intervening with
families earlier might help prevent homelessness for many youth.

Recent longitudinal findings of Courtney et al. (1998) and others suggest that youth with histories of
residential instability, foster care, and other out-of-home placements are at heightened risk for
homelessness during both adolescence and in early adulthood. Such groups could be targeted for
intervention. For youth in public institutions including foster care, juvenile detention, and psychiatric
institutions, more careful and effective discharge planning may be helpful in preventing subsequent
homelessness. However, more knowledge is needed about what specific elements might constitute.
Furthermore, it is critical that youth be tracked for a substantial period of time following discharge, since
homeless episodes may not be immediate but can occur months after the discharge.

Another way to prevent homelessness is to create more alternative residential settings for youth. Policies
could continue to encourage foster placement with extended family members who would take in youth
who have already (or who are about to) separate from their family of origin. Some homeless youth
already make use of extended family members as an occasional housing resource, suggesting their
desirability as a placement. This strategy may increase the ability or motivation of extended family
members to house the youth.

For foster youth, independent living skills programs could be upgraded for youth in foster care preparing
for independent living (e.g., those "aging out" of the foster care system at age 18). The age of eligibility
for foster care or other placements could be extended to age 21 or later. Another strategy would be to
extend support services one to two years beyond the exit from foster care. A striking number of
homeless youth become homeless upon separation from foster or group home placements. We suggest
that special training for foster parents dealing with high-risk youth, especially those who have already
been homeless, might help extend periods of residential stability.

Policy Issues

Residential Options. As is true for homeless adults, long-term housing with independent-living services
is needed. Transitional services also are needed. Most services for youth and young adults are
emergency or short-term, with care limited to crisis periods. Youth who lack basic skills such as money
management, education, and vocational training need intensive support to achieve independent living. A
recent national evaluation of the Transitional Living Program (TLP) for Homeless Youth (based on a

National Symposium on Homelessness Research 3-19

Homeless Youth: Research, Intervention, and Policy

quasi-experimental design implemented in 10 sites with 175 homeless youth, most ages 18 to 21), found
some positive program effects over a 6-month follow-up period (MacAllum, Kerttula, & Quinn, 1997).

Youth Advocacy and Legal Issues. Greater monitoring of foster homes and group homes may be needed
to protect youth while they are in placement. Assigning caseworkers or special advocates to work with
the individual youth may help identify and resolve problems before youth leave placements or
institutional settings (English, 1991). Homeless youth who are minors often are denied services because
of their legal status and the consequent need for parental consent. State laws vary considerably regarding
a minor's ability to give consent. In many states, it is technically illegal to be a homeless minor not under
the supervision of a guardian. In most states, unemancipated minors can legally give consent for care for
some services as mentioned earlier. However, legislative guarantees are needed to delineate
circumstances under which homeless minors may consent to other types of services (English, 1991;
Johnson, Aschkenasy, Herbers, & Gillen water, 1993; Kennedy et al., 1990). Requirements to establish
emancipation could be simplified or could be changed to increase youth access to entitlement programs,
health care, and other services, without necessarily relieving the parent of responsibility.

The recently passed federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996
(P.L. 104-193) replaced the Aid to Dependent Children (ADC) program with the Temporary Assistance
to Needy Families (TANF) program nationwide. Under provisions of TANF, teen parents receiving
assistance must now live under the supervision of a guardian. While these welfare reforms have been
politically popular, they may serve to make if even more difficult for homeless youth who have children
to receive welfare benefits. Youth without children, even those who are legally emancipated minors,
have virtually no access to public assistance in most localities. It is our view that, if the goal is to serve
homeless youth better, expanding eligibility for benefits, rather than further restricting them, may be the
better policy course.

Youth Leaving State Institutions. Not all homeless youth have received services from state youth-care
agencies such as foster care, group homes, or juvenile detention. However, these represent an important
subgroup of the larger homeless youth population (Mangano, 1999). Mangano suggests three key
components for any youth-care agency that seeks to reduce and end homelessness among those it serves:
discharge planning, aftercare tracking, and expanding "next-step" residential options. Early in the case-
management process, agency caseworkers could develop service plans for clients that help youth
establish and maintain contacts with community resources (such as health care, job training, and
recreation) that would ideally continue after discharge. He also suggests that aftercare tracking (which is
rarely done currently) will allow state agencies to review their effectiveness in preparing the youth for a
return to their families or independent living. Finally, nn increase in the number of "next-step"
residential and housing resources is needed since youth who have been in state care or institutions often
have less skills or resources needed to maintain their own housing. Such residential options could
include a variety of supports such as substance abuse and mental health services, life-skills training, and
peer counseling.

Evidence is mounting that the lack of discharge planning and aftercare at state agencies can leave youth
and young adults ill-prepared for a return to their families or for independent living. Providers suggest
that increased aftercare tracking by state agencies would help inform discharge planning and other efforts
to prevent homelessness among at-risk youth.

3-20 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Recommendations for Future Research

Needs Assessment: Methodological Issues

Sampling and Measurement. Many studies on homeless youth provide only very sketchy information
on the sampling methods used. Researchers studying homeless adults have recently found important
differences depending on the sources of their samples (e.g., Hannappel, Calsyn, & Morse, 1989; Link et
al., 1994 ; Robertson, Zlotnick, and Westerfelt, 1998; Toro et al., 1999b; Toro & Wall, 1991). Studies of
homeless youth (Greene et al., 1997) reviewed in this paper suggest that sampling effects may be even
greater for homeless youth.

We recommend that future research on homeless youth carefully document the sampling methods used.
A growing number of large-scale studies of homeless adults have refined probability sampling
procedures for selecting representative groups from a variety of settings across large geographical areas
(e.g., Dennis, 1991; Koegel, Burnam, & Morton, 1996; Robertson, Zlotnick, and Westerfelt, 1997; Toro
et al., 1999b). We recommend that future research consider adapting such methods for homeless youth
(we are aware of only one ongoing study that has done this; see Toro et al., 1998).

Another common flaw in the existing research literature involves the use of standardized instruments
without documented reliability and validity for use with homeless youth. In addition, very few common
measures have been used across studies, making comparison of findings difficult. We recommend that
researchers give more attention to documenting the psychometric properties of standardized measures
they use and, where appropriate, use measures that have been used in previous studies to enhance
comparability across studies.

Comparison Groups. The existing literature tends to paint a rather disturbing picture of the homeless
youth population. Homeless youth seem to have multiple, often overlapping problems, including serious
medical and emotional health problems, substance abuse, sexual and social risk taking, and poor
educational attainment. However, without appropriate comparison groups, it is impossible to determine
the degree to which these problems are unique to homeless youth. While recent studies on homeless
adults and families have benefited from appropriate comparison groups (e.g., Shinn, Knickman, &
Weitzman, 1991; Sosin, 1992; Toro et al., 1995; Wood, Valdez, & Hayashi, 1990), few studies on
homeless youth have included appropriate comparisons (see McCaskill et al., 1998; Wolfe et al., 1999).
Comparison groups are essential to get a clearer picture of the unique features that distinguish homeless
youth from other youth.

Also, carefully analyzed qualitative interview data has proven useful in understanding the needs of
homeless adults and families (Banyard, 1995; Koegel, 1992; Underwood, 1993) and a few such studies
have been done on homeless youth (e.g., Lagloire, 1990). Similar approaches to needs assessment may
be useful in studies of homeless youth. When assessing the needs of homeless youth, we believe that it is
important to include the opinions of the youth themselves.

Longitudinal Research. Though there is a growing number of longitudinal studies on homeless adults
and families (e.g., Shinn et al., 1998; Toro, Goldstein, Rowland, Bellavia, Wolfe, Thomas et al., 1999a;
Toro et al., 1997; Zlotnick, Robertson, and Lahiff, 1999), there have been only a few such studies on
homeless youth. The intervention research of Cauce et al. (1993, 1994a) represents another recent
example of longitudinal research on homeless youth and there are at least three ongoing longitudinal
studies (Albornoz et al., 1998; Cauce et al., 1994b; Toro et al., 1998). Much more work of this type is

National Symposium on Homelessness Research 3-21

Homeless Youth: Research, Intervention, and Policy

needed to help us understand what happens to homeless youth over time and what services and other
resources seem to help them achieve positive long-term outcomes as they approach adulthood.

Strengths Versus Deficits. The existing research and professional literature has focused intently on the
problems and deficits of homeless youth. Virtually no attention has been paid to the strengths and
competencies these youth may possess.

Geographic Coverage. Further research is also needed to document needs of homeless youth in rural
areas, smaller urban centers and in the central US.

Program Evaluation

There is a paucity of research evidence about best practices for meeting the needs of homeless youth.
We need research around the effectiveness of case management, primary care, mental health and
substance abuse services much in the same way that we have research for the adult systems. We would
be interested in knowing not only what works, but under what conditions, for which groups, and at what
cost.

Most shelters and other services for homeless youth have not been systematically evaluated. One
exception comes from work by Cauce and her colleagues who have used an experimental design to
evaluate an intensive case management program for street youth in Seattle (Cauce et al., 1993, 1994a).
More such rigorous designs, including control groups, are needed to determine which approaches to
assisting homeless youth are most effective. Another is a recent national evaluation of the Transitional
Living Program (TLP) for Homeless Youth (based on a quasi-experimental design implemented in 10
sites with 175 homeless youth, most ages 18 to 21), which found some positive program effects over a 6-
month follow-up period (MacAllum, Kerttula, & Quinn, 1997).

We recommend that the organization and financing of services for homeless youth be informed by
reliable information about the population and its needs. Input from service providers, policy makers, and
other community leaders can also inform research on this population (Acosta & Toro, 1999).

3-22 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

References

Ackley, K. A., & Hoyt, D. R. (1997). Suicidal Behavior among Homeless and Runaway Adolescents:
The Test of a Theoretical Model. Paper presented at the Biennial Meeting of the Society for Research on
Child Development, Washington, DC, April.

Acosta, O. & Toro, P. A. (1999, in press). Let's Ask the Homeless People Themselves: A Needs
Assessment Based on a Probability Sample of Adults. American Journal of Community Psychology, 26.

Albornoz, M., Montgomery, S. & Kipke, M. (1998). Prevalence Rates of Alcohol and Drug Use and
Their Long-Term Effects on the Health of Homeless/Runaway Youth Recruited into a Longitudinal
Study. Paper presented at the Annual Meeting of the American Public Health Association, Washington,
DC. October.

Allen, D. M., Lehman, J. S., Green, T. A., Lindergren, M. L., Onorato, I. M., & Forrester, W. (1994).
HrV Infection among Homeless Adults and Runaway Youth, United States, 1989-1992. AIDS, 8(1 1):
1593-1598.

Appelbaum, R. P. (1990). Counting the Homeless. In J. Momeni (Ed.), Homelessness in the United
States: Data and Issues. New York: Praeger.

Banyard, V. L. (1995). "Taking Another Route:" Daily Survival Narratives from Mothers Who Are
Homeless. American Journal of Community Psychology, 23, 871-891.

Blau, J. (1992). The Visible Poor: Homelessness in the United States. New York: Oxford University
Press.

Blumberg, L. U., Shipley, T. E. & Barsky, S. F. (1978). Liquor and Poverty: Skid Row as a Human
Condition. New Brunswick, NJ: Rutgers Center of Alcohol Studies.

Boesky, L. M., Toro, P. A., & Bukowski, P. A. (1997). Differences in Psychosocial Factors among
Older and Younger Homeless Adolescents Found in Youth Shelters. Journal of Prevention and
Intervention in the Community, 15(2): 19-36.

Boesky, L. M., Toro, P. A., & Wright, K. L. (1995). Maltreatment in a Probability Sample of Homeless
Adolescents: A Subgroup Comparison. Annual Meeting, American Public Health Association, San
Diego, CA. November.

Bukowski, P. A., & Toro, P. A. (1996). Differences Among Comparable Samples of Homeless
Adolescents and Adults. 104th Annual Convention, American Psychological Association, Toronto,
Canada. August.

Burt, M. R. (1998). Demographics and Geography: Estimating Needs. National Symposium on
Homelessness Research: What Works? Washington, DC. October.

National Symposium on Homelessness Research 3-23

Homeless Youth: Research, Intervention, and Policy

Busen, N. H. & Beech, B. (1997). A Collaborative Model for Community-Based Health Care Screening
of Homeless Adolescents. Journal of Professional Nursing 13(5): 316-324.

Cauce, A. M., Morgan, C. J., Shantinath, S. D., Wagner, V., Wurzbacher, K., Tomlin, S., & Blanchard,
T. (1993). Intensive Case Management for Homeless Youth: A Description of a Study in Progress.
Community Psychologist, 26(2): 32-34.

Cauce, A. M., Morgan, C. J., Wagner, V., Moore, E., Sy, J., Wurzbacher, K., Weeden, K., Tomlin, S., &
Blanchard, T. (1994a). Effectiveness of Intensive Case Management for Homeless Adolescents: Results
of a 3-month Follow-up. Journal of Emotional and Behavioral Disorders, 2(4): 219-227.

Cauce, A. M., Paradise, M., Embry, L., Morgan, C, Lohr, Y., Theofelis, J., Sy, J., & Wagner, V. (1997).
Homeless Youth in Seattle: Youth Characteristics, Mental Health Needs, and Intensive Case
Management. Unpublished manuscript, Department of Psychology, University of Washington.

Cauce, A. M., Whitbeck, L. B., Wagner, V., Morgan, C. J., Moore, E. J., & Ryan-Finn, K. D. (1994b).
Homeless Youth: Alcohol Abuse and Psychosocial Risk. Unpublished grant proposal (funded by the
National Institute on Alcohol Abuse and Alcoholism), Department of Psychology, University of
Washington, Seattle, WA.

Chelimsky, E. (1982). The Problem of Runaway and Homeless Youth, Oversight Hearing on Runaway
and Homeless Youth Program. Washington, D.C.: Govt. Printing Office. 2-13.

Citizens' Committee for Children of New York. (1983). Homeless Youth in New York City: Nowhere to
Turn. New York: Citizens' Committee for Children of New York and the Coalition for the Homeless
Runaway and Homeless Youth Advocacy Project.

Clark, R. & Robertson, M J. (1996). Surviving for the Moment: A Report on Homeless Youth in San
Francisco. Berkeley: Alcohol Research Group.

Council of Community Services. (1984). Homeless Older Adolescent (16-21 year olds) Needs in Albany
County. Albany, NY: Council of Community Services of Northeastern New York.

Courtney, M. E., Piliavin, I., Grogan-Kaylor, A., & Nesmith, A. (1998). Foster Youth Transitions to
Adulthood: Outcomes 12 to 18 Months After Leaving Out-of-Home Care. Unpublished manuscript,
Institute for Research on Poverty, University of Wisconsin-Madison.

Dempsey, C. L. (1994). Health and Social Issues of Gay, Lesbian, and Bisexual Adolescents. Families
in Society, 75: 160-167.

Dennis, M. L. (1991). Changing the Conventional Rules; Surveying Homeless People in
Nonconventional Locations. Housing Policy Debate, 2: 701-732.

Durlak, J. A., & Wells, A. M. (1997). Primary Prevention Mental Health Programs for Children and
Adolescents: A Meta-Analytic Review. American Journal of Community Psychology, 25: 1 15-152.

3-24 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

English, A. (1991). Runaway and Street Youth At Risk for HIV Infection: Legal and Ethical Issues in to
Care. Journal of Adolescent Health, 72(7): 504-510.

Family & Youth Services Bureau. (1996). Reconnecting Youth and Community. A Youth Development
Approach. Washington, DC: U. S. Department of Health and Human Services, Administration for
Children and Families.

Farrow, J. A., Deisher, M. D., Brown, M. D., Kulig, M. D. & Kipke, M. D. (1992). Health and Health
Needs of Homeless and Runaway Youth. Journal of Adolescent Health, 13: 717-726.

Feitel, B., Margetson, N., Chamas, R., Lipman, C. (1992). Psychosocial Background and Behavioral and
Emotional Disorders of Homeless and Runaway Youth. Hospital and Community Psychiatry, 43(2):
155-159.

Foscarinis, M. (1991). The Politics of Homelessness: A Call to Action. American Psychologist, 46:
1232-1238.

Greater Boston Emergency Network. (1985). Ride a Painted Pony On a Spinning Wheel Ride. Boston,
MA: Massachusetts Committee for Children and Youth.

Greenblatt, M. & Robertson, M. J. (1993). Homeless Adolescents: Lifestyle, Survival Strategies and
Sexual Behaviors. Hospital and Community Psychiatry, 44: 1177-1180.

Greene, J. M., Ennett, S. T., & Ringwalt, C. L. (1997). Substance Abuse Among Runaway and
Homeless Youth in Three National Samples. American Journal of Public Health, 87: 229-235.

Haas, B. E., & Rahn, K. (1995). Michigan Youth in Crisis: Five-Year Data Report, 1990-1994.
Lansing, MI: Michigan Network of Runaway, Homeless, and Youth Services.

Hannappel, M., Calsyn, R. J., & Morse, G. A. (1989). Mental Illness in Homeless Men: A Comparison
of Shelter and Street Samples. Journal of Community Psychology, 17: 304-310.

Hemmens, K. C, & Luecke, M. R. (1988). Sheltering Homeless Youth: A Guide to Illinois Laws and
Programs. Chicago: The Chicago Law Enforcement Study Group.

Hoyt, D. R., & Ryan, K. D. (1997). Victimization of Homeless Youth: An Analysis of Risk Factors
Over Time. Paper presented at the Biennial Meeting of the Society for Research on Child Development,
Washington, DC. April.

Institute of Medicine. (1988). Homelessness, Health, and Human Needs. Washington, D.C.: National
Academy Press.

Jahiel, R. I. (1992). Toward the Prevention of Homelessness. In R. I. Jahiel (Ed.). Homelessness: A
Prevention-Oriented Approach. Baltimore: Johns Hopkins University Press, 315-334

Johnson, T. P., Aschkenasy, J. R., Herbers, M. R., & Gillenwater, S. A. (1993). Self-Reported Risk
Factors for AIDS Among Homeless Youth. Annual Meeting of the Society for Pediatric Research,
Washington, D.C.

National Symposium on Homelessness Research 3-25

Homeless Youth: Research, Intervention, and Policy

Kennedy, J. T., Petrone, J., Deisher, R. W., Emerson, J., Heslop, P., Bastible, D., & Arkovitz, M. (1990).
Health Care for Familyless, Runaway Street Kids. In P. W. Brickner, L. K. Scharer, B. A. Conanan, M.
Savarese, & B. C. Scanlan (Ed.), Under the Safety Net: The Health and Social Welfare of the Homeless
in the United States. New York: W. W. Norton, 82-1 17.

Kennedy, M. R. (1991). Homeless and Runaway Youth Mental Health Issues: No Access to the System.
Journal of Adolescent Health, 12: 576-579.

Kipke, M. D., Montgomery, S., & MacKenzie, R. G. (1993). Substance Use Among Youth Seen At a
Community-Based Health Clinic. Journal of Adolescent Health, 14(4): 289-294.

Kipke, M. D., O'Conner, S., Palmer, R., & MacKenzie, R. G. (1995). Street Youth in Los Angeles:
Profile of a Group At High Risk for Human Immunodeficiency Virus Infection. Archives of Pediatric
Adolescent Medicine, 149: 513-519.

Koegel, P. (1992). Understanding Homelessness: An Ethnographic Approach. In R. I Jahiel (Ed.),
Homelessness: A Prevention-Oriented Approach. Baltimore: Johns Hopkins University Press, 127-138.

Koegel, P., Burnam, A., & Morton, S. C. (1996). Enumerating Homeless People: Alternative Strategies
and Their Consequences. Evaluation Review, 20: 378-403.

Kondratas, A. (1991). Housing Policy and Homelessness in the United States. American Psychologist,
46: 1226-1231.

Kondratas, A. (1994). Comment on Dennis P. Culhane et al.'s, Public Shelter Admission Rates in
Philadelphia and New York City: The Implications of Turnover for Sheltered Population Counts.
Housing Policy Debate, 5: 153-162.

Koopman, C, Rosario, M., & Rotheram-Borus, M. J. (1994). Alcohol and Drug Use and Sexual
Behaviors Placing Runaways At Risk for HIV Infection. Addictive Behaviors, 19: 95-103.

Lagloire, R. (1990). Growing Up Too Fast: An Ethnography of Sexually Exploited Youth in San
Francisco. Unpublished report, Office of Criminal Justice Planning, Sacramento, CA.

MacAllum, C, Kerttula, M. A., & Quinn, E. (1997). Evaluation of the Transitional Living Program for
Homeless Youth: Phase 11 Report. Unpublished report to the Administration on Children, Youth and
Families by CSR, Inc., Washington, DC.

MacLean, M. G., Embry, L. E., & Cauce, A. M. (1999, in press). Homeless Adolescents' Paths to
Separation From Family: Comparison of Family Characteristics, Psychological Adjustment, and
Victimization. Journal of Community Psychology, 27(2): 179-188.

Mangano, P. F. (1999). Homeless Youth: Research, Intervention, and Policy. Review and
Recommendations. Personal communication, April 29.

3-26 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Manrique, M. A., & Toro, P. A. (1995). Lifetime Prevalence of Homelessness in the United States.
Paper presented at the 103rd Annual Convention of the American Psychological Association, New York,
NY, August.

McCaskill, P. A., Toro, P. A., & Wolfe, S. M. (1998). Homeless and Matched Housed Adolescents: A
Comparative Study of Psychopathology. Journal of Clinical Child Psychology, 27: 306-319.

McChesney, K. Y. (1987). Characteristics of the Residents of Two Inner-City Emergency Shelters for
the Homeless. Los Angeles: Social Science Research Institute, University of Southern California.

McClure, D., & Dickman, J. (1988). Homelessness (Research No. 237). Legislative Research
Commission.

Miller, D., Hoffman, F., & Duggan, R. (1980). Runaways - Illegal Aliens in Their Own Land. Brooklyn,
NY: Praeger Publishers.

Miller, H. (1991). On the Fringe: The Dispossessed in America. Lexington, MA: DC Heath.

Moos, R. H., & Moos, B. S. (1994). Family Environment Scale Manual (3rd. Ed.). Palo Alto, CA:
Consulting Psychologist Press.

Morey, M. A., & Friedman, L. S. (1993). Health Care Needs of Homeless Adolescents. Current
Opinion in Pediatrics, 5(4): 395-399.

Morse, G., Calsyn, R. J., Allen, G., Tempelhoff, B., & Smith, R. (1992). Experimental Comparison of
the Effects of Three Treatment Programs for Homeless Mentally 111 People. Hospital and Community
Psychiatry, 43: 1005-1010.

Mundy, P., Robertson, J. M., Greenblatt, M., & Robertson, M. J. (1989). Residential instability in
adolescent psychiatric inpatients. Journal of the American Academy of Adolescent and Child Psychiatry,
28: 176-181.

Mundy, P., Robertson, M. J., Robertson, J. M., & Greenblatt, M. (1990). The Prevalence of Psychotic
Symptoms in Homeless Adolescents. Journal of the American Academy of Child and Adolescent
Psychiatry, 29: 724-731.

National Network of Runaway and Youth Services Inc. (1985). to Whom Do They Belong? A Profde of
America's Runaways and Homeless Youth and the Programs That Help Them. Washington, D.C.:
National Network of Runaway and Youth Services, Inc.

New York State Council on Children and Families. (1984). Meeting the Needs of Homeless Youth.
Albany, New York: Author.

Olson, L., Liebow, E., Mannino, F. & Shore, M. (1980). Runaway Children Twelve Years Later: A
Follow Up. Journal of Family Issues, I, 165-188.

Owen, G., Heineman, J., Minton, C, Lloyd, B., Larsen, P., & Zierman, C. (1998). Minnesota Statewide
Survey of Persons Without Permanent Shelter: Volume II, Unaccompanied Youth. St. Paul, MN: Wilder
Foundation.

National Symposium on Homelessness Research 3-27

Homeless Youth: Research, Intervention, and Policy

Pedro-Carroll, J. L., Cowen, E. L., Hightower, A. D., & Guare, J. C. (1986). Preventive Intervention
With Latency-Aged Children of Divorce: A Replication Study. American Journal of Community
Psychology, 14: 277-290.

Powers, J. L., Eckenrode, J., & Jaklitsch, B. (1990). Maltreatment Among Runaway and Homeless
Youth. Child Abuse and Neglect, 14: 87-98.

Price, R. M., Cowen, E. L., Lorion, R. P. & Ramos-McKay, J. (1988). Fourteen Ounces of Prevention:
A Casebook for Practitioners. Washington, DC: American Psychological Association.

Reed, N. Y. (1994). Family Constellation and Outcomes Among Homeless Adolescents and Their Peers.
102nd Annual Convention, American Psychological Association, Los Angeles, August.

Ringwalt, C. L., Greene, J. M., Robertson, M. (1998a). Risk Behaviors, Negative Familial Experiences,
and Institutional Placements Among Throwaway Youth. Journal of Adolescence, 21: 241-252.

Ringwalt, C. L., Greene, J. M., Robertson, M. & McPheeters, M. (1998b). The Prevalence of
Homelessness Among Adolescents in the United States. American Journal of Public Health, 88(9):
1325-1329.

Robertson M. J. & Greenblatt, M. (1992). Homelessness: A National Perspective. New York: Plenum
Press.

Robertson, M. (1991). Homeless Youths: An Overview of Recent Literature. In J. Kryder-Coe, L.
Salmon, 8i J. Molnar (Eds.), Homeless Children and Youth: A New American Dilemma. New
Brunswick; London: Transaction Publishers, 33-68.

Robertson, M. J. (1989). Homeless Youth in Hollywood: Patterns of Alcohol Use. A Report to the
National Institute on Alcohol Abuse and Alcoholism (Report No. C51). Berkeley: Alcohol Research
Group.

Robertson, M. J. (1992). The Prevalence of Mental Disorder Among Homeless People. In R. I. Jahiel
(Ed.), Homelessness: A Prevention-Oriented Approach. Baltimore: Johns Hopkins Press.

Robertson, M. J. (1996). Homeless Youth on Their Own. Berkeley, Ca: Alcohol Research Group.

Robertson, M. J., Koegel, P., & Ferguson, L. (1989). Alcohol Use and Abuse Among Homeless
Adolescents in Hollywood. Contemporary Drug Problems, Fall: 415-452.

Robertson, M. J., Zlotnick, C, & Westerfelt, A. (1997). Drug Disorders and Treatment Contact Among
Homeless Men and Women in Alameda County, California. American Journal of Public Health, 87:

221-228.

Robins, I. N., & O'Neal, P. (1959). The Adult Prognosis for Runaway Children. American Journal of
Orthopsychiatry, 29: 752-761.

Rosenthal, D., Moore, S., & Buzwell, S. (1994). Homeless Youth: Sexual and Drug-Related Behavior,
Sexual Beliefs, and HIV/AIDS Risk. AIDS Care, 6(1): 83-94.

3-28 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Rossi, P. H. (1989). Down and Out in America: The Origins ofHomelessness. Chicago, IL: The
University of Chicago Press.

Rossi, P. H. (1994). Comment on Dennis P. Culhane et al.'s Public Shelter Admission Rates in
Philadelphia and New York City: The Implications of Turnover for Sheltered Population Counts.
Housing Policy Debate, 5: 163-176.

Rotheram-Borus, M. J. (1991). Serving Runaway and Homeless Youths. Family and Community
Health, 14(3), 23-32.

Rotheram-Borus, M. J. (1993). Suicidal Behavior and Risk Factors among Runaway Youths. American
Journal of Psychiatry, 150(1), 103-107.

Rotheram-Borus, M. J., Koopman, C, & Ehrhardt, A. (1991). Homeless Youths and HIV Infection.
American Psychologist, 46: 1188-1197.

Rotheram-Borus, M. J., Meyer-Bahlburg, H. F. L., Koopman, C, Rosario, M., Exner, T. M., Henderson,
R., Matthieu, M. & Gruen, R. S. (1992a). Lifetime Sexual Behaviors among Runaway Males and
Females. Journal of Sex Research, 29(1), 15-29.

Rotheram-Borus, M. J., Meyer-Bahlburg, H. F. L., Rosario, M., Koopman, C, Haignere, C. S., Exner, T.
M., Matthieu, M., Henderson, R. & Gruen, R. S. (1992b). Lifetime Sexual Behaviors Among
Predominantly Minority Male Runaways and Gay /Bisexual Adolescents in New York City. AIDS
Education and Prevention, Supplement(Fall), 34-42.

Rothman, J., & David, T. (1985). Status Offenders in Los Angeles County: Focus on Runaway and
Homeless Youth. Bush Program in Child and Family Policy. Los Angeles: University of California.

Russell, L. A. (1998J. Child Maltreatment and Psychological Distress Among Urban Homeless Youth.
New York: Garland Publishing.

Ryan, P., Goldstein, I., & Bartelt, D. (1989). Homeless in Pennsylvania: How Can This Be? Coalition
on Homelessness in Pennsylvania and the Institute for Public Policy Studies of Temple University.

Sedlak, A. J., Schultz, D. J., Wiener, S., & Cohen, B. (1997). National Evaluation of Runaway and
Homeless Youth: Final Report. Unpublished report to the Administration on Children, Youth and
Families by The Urban Institute, Washington, DC.

Shinn, M., Knickman, J. R., & Weitzman, B. C. (1991). Social Relations and Vulnerability to Becoming
Homeless Among Poor Families. American Psychologist, 46(11): 1180-1187.

Shinn, M., Weitzman, B. C, Stojanovic, D., Knickman, J. R., Jimenez, L., Duchon, L., James, S., &
Krantz, D. H. (1998). Predictors ofHomelessness Among Families in New York City: From Shelter
Request to Housing Stability. American Journal of Public Health, 88: 1651-1657.

National Symposium on Homelessness Research 3-29

Homeless Youth: Research, Intervention, and Policy

Shlay, A. B., & Rossi, P. H. (1992). Social Science Research and Contemporary Studies of
Homelessness. Annual Review of Sociology, 18: 129-160.

Solarz, A. L. (1988). Children Without Homes. Social Policy Report: Society for Research in Child
Development, 3(4).

Sosin, M. R. (1992). Homeless and Vulnerable Meal Program Users: A Comparison Study. Social
Problems, 39: 170-188.

Stricof, R. L., Kennedy, J. T., Nattell, T. C, Weisfuse, I. B., & Novick, L. F. (1991). HIV
Seroprevalence in a Facility for Runaway and Homeless Adolescents. American Journal of Public
Health, £7(supplement): 50-53.

Sullivan, P. A., & Damrosch, S. P. (1987). Homeless Women and Children. In R. D. Bingham, R. E.
Green, & S. B. White (Ed.), The Homeless in Contemporary Society. Newbury Park, Ca.: Sage
Publications, 82-98.

Susser, E. S., Streuning, E. L., & Conover, S. (1987). Childhood Experiences of Homeless Men.
American Journal of Psychiatry, 144: 1599-1601.

Toro, P. A. (1998). Homelessness. In A. S. Bellack & M. Hersen (EdsJ, Comprehensive Clinical
Psychology: Vol. 9, Applications in Diverse Populations, 1 19-135.

Toro, P. A., & Bukowski, P. A. (1995). Homeless Adolescents: What We Know and What Can Be
Done. NMHA Prevention Update, 6(1): 6-7.

Toro, P. A., & Wall, D. D (1991). Research on Homeless Persons: Diagnostic Comparisons and
Practice Implications. Professional Psychology: Research and Practice, 22: 479-488.

Toro, P. A., & Warren, M. G. (1999, in press). Homelessness in the United States: Policy
Considerations. Journal of Community Psychology, 27(2), 119-136.

Toro, P. A., Bellavia, C, Daeschler, C, Owens, B., Wall, D. D., Passero, J. M., & Thomas, D. M.
(1995). Distinguishing Homelessness From Poverty: A Comparative Study. Journal of Consulting and
Clinical Psychology, 63: 280-289.

Toro, P. A., Goldstein, M. A., & Rowland, L. L. (1998). Preliminary Analyses: Housing, Adolescence
and Life Outcomes (HALO) Project. Wayne State University, Department of Psychology (research
funded by the National Institute on Alcohol Abuse and Alcoholism).

Toro, P. A., Goldstein, M. S., Rowland, L. L., Bellavia, C. W., Wolfe, S. M., Thomas, D. M., & Acosta,
O. (1999a, in press). Severe Mental Illness Among Homeless Adults and Its Association With
Longitudinal Outcomes. Behavior Therapy.

Toro, P. A., Passero Rabideau, J. M., Bellavia, C. W., Daeschler, C. V., Wall, D. D., Thomas, D. M., &
Smith, S.J. (1 997). Evaluating an Intervention for Homeless Persons: Results of a Field Experiment.
Journal of Consulting and Clinical Psychology, 65: 476-484.

3-30 National Symposium on Homelessness Research

Homeless Youth: Research, Intervention, and Policy

Toro, P. A., Wolfe, S. M., Bellavia, C. W., Thomas, D. M., Rowland, L. L., Daeschler, C. V., &
McCaskill, P. A. (1999b, in press). Obtaining Representative Samples of Homeless Persons: A Two-
City Study. Journal of Community Psychology, 27(2): 157-178.

U. S. General Accounting Office. (1989). Children and Youths: About 68,000 Homeless and 186,000 in
Shared Housing at Any Given Time (Report to congressional committees No. PEMD-89-14). U. S.
General Accounting Office.

Underwood, J. (1993). The Bridge People: Daily Life in a Camp of the Homeless. Lanham, MD:
University Press of America.

Upshur, C. C. (1986). Research report: The Bridge, Inc., Independent Living Demonstration,
Amendments to the foster care and adoption assistance program. Hearing before the subcommittee on
public assistance and unemployment compensation of the Committee on Ways and Means, House of
Representatives, 99th Congress (September 19, 1985) (Serial 99-54). Washington, D.C.: Government
Printing Office.

van Houten, T., & Golembiewski, G. (1978). Life Stress As a Predictor of Alcohol Abuse and/or
Runaway Behavior. Washington, D.C.: American Youth Work Center.

Whitbeck, L. B., & Simons, R. L. (1990). Life on the Streets: Victimization of Runaway and Homeless
Adolescents. Youth & Society, 22(1), 108-125.

Whitbeck, L. B., Hoyt, D. R., & Ackley, K. A. (April, 1997a). A Risk-Amplification Model of
Victimization and Depressive Symptoms Among Homeless and Runaway Adolescents. Paper presented
at the Biennial Meeting of the Society for Research on Child Development, Washington, DC.

Whitbeck, L. B., Hoyt, D. R., Tyler, K. A., Ackley, K. A., & Fields, S. C. (1997b). Midwest Homeless
and Runaway Adolescent Project: Summary Report to Participating Agencies. Unpublished manuscript,
Department of Sociology, Iowa State University.

Windle, M. (1989). Substance Use and Abuse Among Adolescent Runaways: A Four-Year Follow-Up
Study. Journal of Youth and Adolescence, 18: 331-344.

Wolfe, S. M., Levit, D., & Toro, P. A. (1994). AIDS Risk Behaviors, Service Use and Social Networks
in Runaway vs. Housed Adolescents. American Public Health Association, Washington, DC, November.

Wolfe, S. M., Toro, P. A., & McCaskill, P. A. (1999, in press). A Comparison of Homeless and
Matched Housed Adolescents on Family Environment Variables. Journal of Research on Adolescence.

Wright, J. D., Rubin, B. A., & Devine, J. A. (1998). Beside the Golden Door: Policy, Politics, and the
Homeless. New York: Aldine de Gruyter.

Yates, G. L., MacKenzie, R., Pennbridge, J., & Cohen, E. (1988). A Risk Profile Comparison of
Runaway and Non-Runaway Youth. American Journal of Public Health, 78: 820-821.

National Symposium on Homelessness Research 3-31

Homeless Youth: Research, Intervention, and Policy

Young, R. L., Godfrey, W., Matthews, B., & Adams, G. R. (1983). Runaways: A Review of Negative
Consequences. Family Relations, 32: 275-281.

Zlotnick, C., Robertson, M. J., & Lahiff, M. (1999). Getting off the Streets: Economic Resources and
Residential Exits From Homelessness. Journal of Community Psychology, 27(2): 209-224.

Zlotnick, C., Robertson, M. J., & Wright, M. (In press). The Impact of Childhood Foster Care and Other
Out-of-Home Placement on Homeless Women and Their Children. Child Abuse and Neglect: The
International Journal.

3-32 National Symposium on Homelessness Research

Making Homelessness Programs Accountable to
Consumers, Funders and the Public

Dennis Culhane, Ph.D.
David Eldridge, M.S.W.
Robert Rosenheck, M.D.

Carol Wilkins, M.P.P.

Abstract

This paper discusses how different types of performance measurement can be used to improve the
accountability of homeless programs to consumers, funders, and to the public. A distinction is made
between the kinds of data used in formal research projects and data that can be practically obtained in a
practice setting. Consumer outcomes are discussed in terms of accountability to consumers, program
outcomes in terms of accountability to funders, and systems outcomes in terms of accountability to the
public. Cost-benefit analyses are also discussed as providing another critical dimension of accountability
to funders and the public.

If performance effectiveness is determined by appropriate measures of consumer need, services
delivered, and outcomes attained, policy makers and practitioners can gain important insight into what
policies have the greatest impact on homelessness and what practices serve homeless people the most
effectively. A reliable performance accounting system will require collaboration among policy makers,
practitioners, and consumers to collect systematic consumer- and program-specific information.

Lessons for Practitioners, Policy Makers, and Researchers

• Outcome-based program evaluation uses methods that range from simple and inexpensive to complex
and resource-intensive. Doing at least some basic outcome measurement provides valuable
information about program effectiveness.

• Research measures and practice measures are necessarily different. For instance, there is tension
between low demand clinical engagement and the intimidation of comprehensive "intake," so it may
not always be possible to get a baseline measurement.

• Standardized data collection at the consumer level is a critical building block. Decisions about
desired program outcomes should include consumer input and results of program evaluations should
be shared with consumers.

• System-wide standards and provider information are needed to compare the relative effectiveness of
program. A number of Management Information Systems (MIS) programs are available that
standardize outcome.

• The homeless system must demonstrate effectiveness to compete with other public priorities.
Funders are increasingly using outcome measures to evaluate programs and make choices about
which programs to fund.

• The homeless system is related to performance of other systems (e.g., health, welfare, and housing)
so evaluating their impact involves complex interagency data acquisition issues.

National Symposium on Homelessness Research 4-1

Making Homeless Programs Accountable to Consumers Funders and the Public

Thorough cost-benefit analysis requires the integration of a large number of data sets that are usually
not compatible, but like any evaluation research a little research concerning a program's cost-
effectiveness can nevertheless be informative.

4-2 National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

Introduction

Funding agencies at all levels of government have begun to consistently use outcome measures to
evaluate the effectiveness of social services. Some local governments have been using outcome-based
evaluations of their programs in their reporting and application for federal funds. The link between
receipt of funding and performance has been further strengthened with the establishment of the
Government Performance and Results Act which obligates federal departments to report on the
performance of all funded programs in meeting their specified objectives by the year 2000.

This paper reviews the literature on homeless services outcomes and discusses how different kinds of
performance measurement can be used to improve the accountability of programs to consumers, funders,
and to the public. In doing so, a distinction is made between the kinds of information gathered by formal
research projects and that which can be practically obtained in a practice setting. Regardless,
accountability should be based on outcome measurements that provide as clear indicators as practicable
that the public and private homeless services are meeting their intended objectives, for consumers,
funders and the public. While each constituency may have interests that cross analytic boundaries, this
paper is organized according to the primary accountability issues for each audience, and the
corresponding level of analysis. Thus, consumer outcomes are discussed primarily in the section on
accountability to consumers, program outcomes in the section on accountability to funders, and systems
outcomes in the section on accountability to the public.

Introduction: Analysis Framework

Level of Accountability

Primary Units of Analysis

Consumers

Consumer Needs
Services Received

Funders

Provider

Public

System

Cost-benefit analyses provide another critical dimension of accountability by weighing the costs of not
conducting programs along with the impact of current programs. These kinds of analyses must
incorporate a range of data, typically in different units of analysis, with varying degrees of reliability, and
from a variety of service systems that use different data management systems. Thus, even less literature
in this area is available than in homelessness outcome measurement evaluation generally, providing
provisional guidance at best. However, this methodology may help to increase accountability and has
been given particular attention in this paper for the potential benefits it offers to policy analysts, program
administrators, and state and local officials.

When performance effectiveness is determined by outcome measures, policy makers and practitioners
gain important insight into what policies have the greatest impact on homelessness and what practices
serve homeless people the most effectively. It must be noted that the needs of consumers and the limited
resources of providers can interfere with the types and extent of measurements that can be reasonably
and reliably gathered. Thus, an active collaboration between policy makers and practitioners is required
to accommodate to the clinical realities that make outcome measurement challenging. Nevertheless,

National Symposium on Homelessness Research

4-3

Making Homeless Programs Accountable to Consumers Funders and the Public

sound policy and good practice require a concerted effort to collect information on what consumers need,
what they receive, and to what effect.

Accountability to Consumers

In order for programs to be accountable to consumers, they must be able to demonstrate responsiveness
to consumers' needs — both as consumers' perceive them, and as may be ascertained through reliable and
clinically appropriate means by service providers. Because consumers and providers often differ in their
views of what consumers need, as well as the relative priority of those needs, multiple methods of
assessment should be used. Correspondingly, to assess the adequacy by which consumers' needs have
been served multiple methods of performance and outcome measurement should also be employed.
These include measures for services provided, consumer progress in meeting service goals, and consumer
satisfaction. The usefulness of these measures for achieving accountability to consumers depends in
large measure on the degree to which these measures are accessible to and reviewed by program staff and
program managers, as well as by consumers. The use of such measures for achieving accountability to
funders and the public will be discussed in later sections; this section will review how they can be used to
increase the accountability of programs to consumers.

Accountability to Consumers: Measurement Strategies

Assessment Type

Methodology

Consumer Preferences

Checklists, Likert scales (domain specific)

Standardized Assessment Tools

Standardized scales, MIS assessment instruments

Match-Mismatch

Compare consumer needs with services delivered
("appropriateness")

Outcomes

Housing stability

Adequate income

Social relationships/functioning

Consumer satisfaction

Quality of life

Consumer-Perceived Needs. Several published studies have reported attempts to gauge what consumers
perceive as their needs and the relative priority of those needs. For example, in an early study of
consumer-defined needs, Ball and Havassy (1984) found that homeless repeat users of psychiatric
facilities in San Francisco prioritized their lack of basic resources for survival, over their lack of access
to social services, as the main cause for their homelessness. Results from the 112 subjects surveyed
identified the following needs: affordable housing (44%), financial entitlements (38%), alcohol treatment
(9%), and counseling (7%). More recently, a needs assessment study conducted as part of the Access to
Community Care and Effective Services and Supports (ACCESS) program found that among 1,482
homeless people with mental illness, 91 percent identified a need for long-term housing, including 61
percent who identified this as one of their top three needs (Rosenheck & Lam, 1997b). In each case, long
term housing was the most frequently identified need. But it was clearly not the only need. Other needs,
in order of importance, were for mental health services (78%), dental services (73%), medical services

4-4

National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

(72%), financial assistance (70%), help getting a job (56%) and substance abuse treatment (28%). Other
studies of consumer preferences have employed similar measures, and derived similar conclusions (see
Herman, Stuening & Barrow, 1994; Moxley & Freddolino, 1991; Acosta & Toro, in press; Linn &
Gelberg, 1989).

Compared to assessments of homeless consumers' psychiatric status, employment history, or substance
use history, these studies of consumer-perceived needs have employed relatively simple and
straightforward surveys of consumer preferences that are quick and easy to complete. Consumer-
perceived needs tend to be assessed in fairly broadly conceived domains, with standard Likert-type
scales, checklists, or rank ordered lists. In some cases, such as those assessing consumers' preferences
for a specific type of housing placement, more detailed questions may be asked. Nevertheless,
standardized, psychometrically tested (i.e., tested for reliability and validity) instruments, have not been
developed in this area. This has been due to the presumption that consumers can accurately describe
what they want, and how much they want it, without major threats to validity. The reliance on
consumers to identify their own needs helps alter the focus of practitioners, researchers, and policy
makers from measuring dysfunctions to determining survival skills and assessing consumer aspirations
(Friedman, 1998).

Of course, consumers' and case managers' assessments of consumer needs are not always in
concordance. One study that measured the discrepancy between these assessments is the study
mentioned above from the ACCESS program (Rosenheck & Lam, 1997b). In that study assessment data
gathered from consumers were matched with similar needs assessments from providers in the same
domains (mental health, general health, substance abuse, public support, housing assistance/support,
dental care, and employment). The greatest consumer/provider differences in perceived service needs
were in dental services (identified by 73% of consumers, but only 44% of providers); medical service
(identified by 72% of consumers but only 55% of providers); substance abuse services (identified by only
28% of consumers but 44% of providers) and mental health services (identified by 78% of consumers
and 93% of providers). Mental health providers were thus less likely than consumers to identify needs
for non-mental health services, but more likely to identify needs for mental health services. Awareness
and respect for the potential discrepancies between consumer and provider needs assessments is
important: it can help agencies in their self-evaluation process to reflect on their missions, and to affirm a
more consumer-centered approach to policy, program design and/or advocacy. Thus, simple consumer
surveys conducted periodically can offer program managers with a useful self-study tool for improving
their accountability to consumers.

Standardized Assessment Tools

More traditional consumer assessment techniques usually take the form of an intake interview.
Researchers, focused as they are on obtaining thorough data, have created many standardized instruments
to assess a broad range of consumer characteristics. Since homeless people typically have a multiplicity
of problems, consumers' needs must be assessed along multiple dimensions: housing; health status
(including psychiatric illness, substance abuse, and medical and dental problems); income support;
access to necessities such as food and clothing; social support; employment; involvement in the criminal
justice system; and access to health care and/or social or vocational, rehabilitation services. In addition
to these specific components there is also value to assessing quality of life according to a global
assessment (Lehman, 1988), and general satisfaction with services (Attkisson & Greenfield, 1996;
Rosenheck, Wilson & Meterko, 1997). Assessment is further complicated by the fact that each of these
domains may have multiple sub-components. For example, housing status can be assessed by the number
of days a consumer has been free of homelessness in the past 30 days; by the stability of their residence

National Symposium on Homelessness Research 4-5

Making Homeless Programs Accountable to Consumers Funders and the Public

(how many times they have moved in the past 6 months); by the quality of the housing (safety, state of
repair, privacy, proximity to transportation etc.); or by the number and type of people with whom they
reside.

In general, it is best to use standard measures of health outcome that have well-characterized validity and
reliability. There are typically numerous measures to chose from. In the ACCESS program psychiatric
status is assessed by self-reported symptoms of depression (Robins, Helzer, Croughan & Ratcliff, 1981),
psychosis (Dohrenwend, 1976), and interviewer ratings of psychotic behavior on standardized scales.
Substance use was assessed with the composite alcohol and drug indices of the Addiction Severity Index
(ASI) (McLellan, Luborsky, Wood & O'Brien, 1980). Psychological distress can also be measured using
the Brief Symptom Inventory, a 53-item version of the well-known Symptom Checklist-90 (Derogatis &
Spencer, 1982).

One of the major dilemmas evaluators must face is the trade off between obtaining comprehensive data
and consumer tolerance for participating in assessments. To paraphrase Abraham Lincoln, "You can get
all of the data on some of the people, and some of the data on all of the people. But you can't get all of
the data on all of the people." Only people with the least problems and the greatest willingness to
cooperate will complete assessment batteries, and the data will thus not be representative of the
population being served. Moreover, from a service delivery perspective, too many questions may pose a
barrier to engagement of homeless mentally ill consumers. Consequently, most agencies use relatively
brief intake or assessment forms to collect basic demographic information, income status, reasons for
homelessness, educational status, employment status, health status, family issues, etc. These intake
interviews typically do not employ standardized instruments, and their psychometric properties have not
been established. They are more commonly developed to facilitate the planning of direct services for
individual consumers or to verify eligibility, as opposed to answering research questions.

That said, many public agencies, including the federal government, have encouraged the development of
more standardized intake or assessment interviews. For example, for nearly ten years, cities such as New
York, Philadelphia, Columbus (OH), St. Louis, and Maricopa County (Phoenix), have been collecting
basic demographic and psychosocial information on nearly all persons entering emergency shelters. The
Department of Veterans Affairs Health Care for Homeless Veterans (HCHV) Programs and Domiciliary
Care for Homeless Veterans (DCHV) programs have conducted over 150,000 standardized assessments
since beginning operation in 1987, using selected items from standardized instruments (Seibyl,
Rosenheck, Medak & Corwel, 1997; Kasprow, Rosenheck & Chapdelaine, 1997). In addition, many
individual shelters throughout the country have also developed their own intake and assessment tools.

The federal government has also encouraged broader use and standardization of such instruments through
their support for the development of the Participant Outcomes Monitoring System (POMS) (Fosburg,
Locke, Peck & Finkel, 1997), and the Runaway and Homeless Youth Management Information System.
Many jurisdictions are also beginning to implement local Management Information System (MIS), or to
install other consumer-tracking software applications. 1 Because of their automation and consequent
standardization across providers in a jurisdiction, these systems and assessment instruments are very
useful for establishing accountability of programs to funders and to the public (to be discussed later).

One of the authors (D. Culhane) was involved in the development of the ANCHoR system with PRWT Services, Inc.
(Philadelphia, PA). Other Homeless Services MIS systems and their vendors include, SOPHIA by Caracole, Inc. (Cincinnati,
OH), Community Link by Community Services Network (Orlando, FL), Client Track by Data Systems International (Layton,
UT), Homeless Prevention Network by School of ECE, Purdue University (West Lafayette, IN), Locator 2000 by Gulf Coast
Software (Groves, TX), Homeless Services Network by Paradigm Systems, Inc. (Charlotte, NC), FACTORS & HelpWorks by
Peter Martin Associates, Inc. (Chicago, IL), C-STAR by St. Vincent de Paul Village, CSC (San Diego, CA), Homeless
Information System by Colorado Department of Human Services (Denver, CO).

4-6 National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

Even when they do not document outcomes, they indicate that the programs are reaching their intended
target population, an important performance standard that should not be taken for granted. Furthermore,
to the extent that these systems assess consumer needs for housing, employment, and health services, as
well as the services provided to the consumer, consumers can use such systems, or reports generated by
them, to measure how well their needs are being addressed. It should be noted that the administrative
data generated by MIS programs have advantages and disadvantages in terms of reliability and validity
and should be used judiciously like any other kind of data.

Anecdotally, jurisdictions that have implemented automated "consumer tracking" systems or
management information systems (MIS), have reported that consumers more often express appreciation
than complaints that they are interviewed with a formal set of questions. A locality has to weigh the
burden of information gathering against the benefits of having service planning data and outcome
measures, in creating an assessment instrument or information system. However, one way to persuade
consumers to tolerate an intake interview is to inform them that the information will be used to plan their
services, and to keep the service system accountable to them. Consumers should also be actively
involved in devising privacy controls over the personal data that is maintained in MIS programs
(Friedman, 1998). Consumers can benefit directly from the use of MIS by providers because they would
not have to provide the same information to multiple providers and they would be served more
effectively from increased coordination of services. Providers, for example, could facilitate referrals to
programs in other systems for needed services or could notify consumers where emergency shelter beds
or other services are actually available.

Performance Measurement

Once consumers' needs have been identified, it is critical to record the services a consumer actually
receives in order to adequately judge program outcomes. The record of services delivered and the
outcomes attained — often in combination — are referred to as "performance measures." Quantifiable
measures of the services a program provides are essentially the "inputs" against which outcomes can be
measured. Research- and demonstration-oriented projects often have a bundle of services that comprise
the intervention and are presumed to be received by the experimental or intervention group. Therefore,
some demonstration projects will not collect detailed services information. However, in the non-
research, or typical practice setting, consumers access a variety of services of different types and to
different extents. Thus, to assess how outcomes are related to services delivered, thereby providing
another measure of accountability to consumers, some method of recording units of service by type of
service is needed.

This is probably the most variable and difficult aspect of information collection by homeless services
agencies. Again, some of the automated tracking systems mentioned earlier attempt to record the discrete
use of services by type of service. However, this gets very complicated beyond measuring more
traditional units of service, such as nights of shelter provided, and standard units of clinical services (e.g.
mental health outpatient visits). Many social services are unevenly provided and have variations in
intensity, duration, or in the professional level of the staff, and this variability is typically not captured in
denoting a "unit of service." This area deserves more attention by agencies, cities, and researchers who
should work towards a more common understanding of what services and units of services mean in
different settings so that they can be more comparably measured. As one example of the utility of service
use measurements, a Veterans Administration (VA) outcome study was able to demonstrate significant
relationships between outcomes and the number of times consumers were seen, whether they were
contacted through community outreach, the number of days of residential treatment they received, and
whether they received increased public support payments (Rosenheck, Frisman & Gallup, 1995).

National Symposium on Homelessness Research 4-7

Making Homeless Programs Accountable to Consumers Funders and the Public

Whether or not discrete services are measured, programs can still be held accountable to consumers
simply by showing whether or not consumers progress or achieve other intended outcomes. Again,
researchers have been far more careful to collect exhaustive information when trying to assess program
outcomes than is typically possible in a practice setting. In the research setting, assessment tools like
those described previously are typically used as periodic follow-up measures. This would be the
equivalent of repeatedly administering an intake/assessment interview to a consumer. Other instruments
are explicitly designed to collect "outcome" data (i.e., housing stability). But, again, while researchers
typically receive special funds to hire staff to track consumers, to interview them, and to compensate
them for their participation, these are resources that a typical practice setting cannot afford. Still, it is
important to be able to demonstrate to consumers that their participation has real effects in improving the
homeless service system.

To some extent less rigorous outcome measurement has into some of the consumer tracking systems
mentioned earlier. In the VA's HCHV and DCHV programs, mentioned above, a brief discharge form
has been completed after each one of over 50,000 episodes of residential treatment. This form
documents where each veteran will be residing after discharge, their employment status, whether they
completed the program to a mutually agreed upon discharge or premature departure, and staff
assessments of clinical improvement. While these measures lack the rigor and reliability of research-
level measures, they provide useful and face-valid evidence of program results (Rosenheck, Leda &
Gallup, 1992). Some of these consumer-tracking systems not only have assessment forms but also allow
for collecting periodic measures of status in several domains. These relatively consumer-friendly
techniques can be applied to a broader population and tend to be much more brief than an assessment
interview. They can be used to assess whether programs are meeting their objectives in serving either
consumer- or program-identified needs. In some cases, jurisdictions may elect to collect outcome
measures on a sample of discharged consumers, given the difficulty of tracking consumers, especially
after they have left a given program. Indeed, the major challenge in collecting outcomes information is
finding former consumers. Doing so for all discharged consumers would require an unrealistic (and
unjustifiable) expenditure of effort and resources in most cases. Alternatively, some agencies may
choose to follow a sample (i.e., ten-percent) of their consumers for six months, measuring their progress
once or twice over this time period.

The subject of follow-up raises another issue: how long after leaving a program should consumers be
followed? Unfortunately, there are no established standards for this important consideration. Outcome
data are most easily and comprehensively gathered during participation in or at the time of discharge
from a program. However, while some program "graduates" may be tracked through aftercare programs,
these typically represent the most successful exits from a given program. Again, research and
demonstration projects may have the resources to conduct long-term follow-up (perhaps two years or
more) with a broader cohort of service users, while service agencies will have to choose a more practical
strategy. Nevertheless, care should be used to avoid selection biases, whereby only the successful
consumers are followed (sometimes referred to as "creaming").

Accountability to Funders

While it is theoretically possible for consumers to hold programs accountable by reviewing their own
services histories and progress reports, as well as aggregate reports on other consumers (indeed, such a
practice might be encouraged among consumer advocacy groups), providers are more commonly held
accountable by their funders. Funders, especially government funders, will usually enforce

4-8 National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

accountability through annual or periodic reporting requirements, and through applications for new or
renewed funding. Unfortunately, because of the range of funders that may be involved, providers have to
struggle with widely variable and inconsistent reporting requirements. In general, funders tend to require
data elements similar to those used to establish accountability to consumers described above. However,
since funders often must regulate or oversee a large number of programs, and programs of different
types, they may have more generic benchmarking practices. It is worth noting that to the extent that
some large social service agencies have several programs that they directly manage, they might conduct
similar analyses as described here, and could therefore be considered "funders." Some of the more
common reporting formats and issues are discussed below.

Accountability to Funders: Performance Measurement

Components

Measures

Consumers served

Contract Performance (units of service per consumer)

Units of Service delivered

Effectiveness (maximize positive outcomes per consumer)

Outcomes

Efficiency (maximize ratio of positive outcomes :: services
delivered per consumer)

Again, the research literature, where resources are available for tracking consumers and analyzing large
quantities of data, offers only a few examples of detailed provider or program evaluation research. The
vast majority of program evaluations measure either the relative effectiveness of two or three different
program interventions, or the impact of a single program model, implemented by a number of providers.
The first type of program evaluation, which typically uses an experimental or quasi-experimental design,
compares models of housing or services in terms of how well they serve consumers, using aggregated
consumer-level data over time. For example, Miesher and Galanter (1996) experimentally compared two
programs that served homeless alcoholic men according to consumer retention in each program.
(Interestingly, the authors' conclusions point to the importance of service integration, or systems-level
concerns, rather than the program-level issues, in producing better outcomes.)

A second type of program evaluation in the literature derives system-level conclusions by aggregating
program-level outcomes from a large project. For example, Matulef et al.'s (1995) National Evaluation
of the Supportive Housing Demonstration Program evaluates the impact of 93 percent of the over 700
programs that participated in this demonstration project. While this strategy generates information on the
need for systems-level interventions across sites, the relative effectiveness of each program is not
evaluated. Alternatively, Huebner and Crosse (1991) used an innovative approach that combines
experimental and quasi-experimental comparisons with site-level and systems-level analyses for a nine-
site demonstration project evaluation. They conclude that inconsistent definitions of homelessness,
problems with missing data and difficulty in measuring treatment effects were major obstacles to
developing cross-project comparisons. This lack of standardization could similarly frustrate analysts
working within, let alone across, jurisdictions. Finally, from a research perspective, the authors point out
that common instrumentation is not a panacea, but that data-collection procedures and schedules,
comparison groups, and selection into these groups are also important factors to consider in assessing
program effectiveness. Another strategy that may help performance measurement is the institution of
quality standards for providers that are developed in conjunction with consumers (Friedman, 1998).

National Symposium on Homelessness Research 4-9

Making Homeless Programs Accountable to Consumers Funders and the Public

In the Department of Veterans Affairs HCHV and DCHV programs reporting formats are uniform
nationally. A total of 33 "critical monitors" (benchmark measures) are used to evaluate the comparative
performance of over 100 programs across the country in the areas of program structure (6 measures);
contacting the intended target population (7 measures); delivering intended services (8 measures) and
outcomes (11 measures) (Kasprow et al., 1997; Seibyl et al., 1997). Less able or interested in funding
research projects, more typically funders of homeless services will require basic data for reporting
purposes, such as the number of people served, consumer characteristics, and, less often, the needs of
those consumers. They also usually require some description of the program or services provided, and
may even ask for the total number of units of service delivered by service category. Funders have less
traditionally asked for outcomes, but, as stated previously, that is becoming more common as federal,
state, and local governments are more conscious of performance, or employ performance-based auditing
or contracting procedures.

Performance measures can be as crude as units of service per person (efficiency) to more complicated
attempts to link units of services to some desired outcome (efficacy). For example, a funder of homeless
programs may want to know the number of consumers served and the number of shelter days used, and -
in combination - the average length of stay in a program. Given that the residential component of
homeless programs is usually the most significant in terms of cost, the "average length of stay" (ALOS)
is perhaps the most common proxy measure of what a consumer receives, or what the funder is
"purchasing." For some funders, this might constitute performance in that it may document what amount
of service was provided for the average consumer, or in that it may be used to compare the efficiency of
providers in serving a given pool of consumers. However, even this level of reporting is only recently
becoming more common in jurisdictions. To calculate an average length of stay per episode, a provider
must know, at a minimum, the total number of consumer episodes (which may include duplicates of
individuals) and the total number of days of service provided. To calculate average length of stay per
consumer, agencies must furthermore be able to unduplicate consumers across episodes. To do so across
a jurisdiction, or some other grouping of agencies, would undoubtedly require some automated
information system.

Given the rather basic state of reporting at present, research is needed to develop more accurate and
discriminating performance criteria, as well as organizational or service delivery factors that can be
associated with those criteria. The average length of stay is one indicator that has been discussed; still
others might include units of case management delivered, hours of counseling, frequency of outreach
contacts, rate of readmission to shelter, etc. For example, a recent "provider performance" analysis
(Culhane, Eldridge & Metraux, 1999) chose the rate of readmission to shelter as the critical benchmark
for measuring the effectiveness of transitional housing providers. Of particular interest to the funders of
the research was whether or not rate of return was associated with length of stay. In other words, do
shelters with longer lengths of stay have lower rates of return? In later models, length of stay was treated
as a control variable, and the effect of various social services (frequency, duration, etc.) on readmission
rates was assessed (i.e., Does providing case management or a certain amount of it reduce the rate of
return to homelessness?). Still further models included consumer characteristics ("case mix") and
discharge type (percent receiving housing subsidies) as variables. The operationalization of these
variables involved a number of challenging conceptual decisions and statistical procedures.
Nevertheless, the study provides a method for systematically comparing programs while taking account
of variations in consumer mix, service mix, etc., and doing so based primarily on administrative records,
rather than depending exclusively on costly, time-consuming survey methods.

4-10 National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

Accountability to Funders: Benchmarking
Example (Culhane, Eldridge, & Metraux, 1999)

Variables

Required Standardized Data

Dependent Variable: Rate of Return

1 . Consumer needs/characteristics

2. Services delivered

3. Discharge type

4. Provider characteristics

5. System-wide admission data

Independent Variables: Specific services delivered

Control Variables: Length of Stay

Exit type

Case-mix adjustments
Provider characteristics

From a funder's perspective, if more days, or certain services, or more of certain services, are not
associated with reductions in rate of return, one could conclude that those are either poorly performing
programs or are not critically important services. Similarly, one could measure placements to housing,
tenure in housing, increases in income, etc., as performance measures against which various inputs are
measured. In choosing benchmarks, one must be careful that the outcome measures reflect an intended
policy or programmatic objective. For example, some might argue that rate of return, while a readily
available measure in some cities, is really a poor measure of how a person or family is functioning,
particularly given that some persons may prefer to live on the streets instead of return to a shelter. For
these persons, the lack of "return" to shelter would not indicate "success."

Also, as indicated by the preliminary study of provider performance mentioned above (Culhane et al.,
1999), if funders want to be accurate in judging providers, additional sets of data are needed, beyond
length of stay and rate of return. First, consumer characteristic information must be collected so that
adjustments can be made for variations in case mix. Some providers may serve a more chronically
disabled population, and would therefore be expected to have different performance parameters. The VA
programs described previously use over ten baseline measures to risk adjust outcomes assessments that
are used to compare programs seeing different types of patients across the country. Additionally, a
number of provider level characteristics, which cannot be obtained through consumer-tracking systems,
may be important as qualifying or control variables. These may include organizational size, auspices,
funding sources, staffing levels, ownership, revenues by source, expenditures by category, etc. For
example, Rosenheck and Lam (1997a) used ACCESS program data to find that geographic location of
homeless services provider sites was a greater obstacle to service use than consumer characteristics
among homeless persons with serious mental illness.

Thus, in addition to implementing consumer tracking information systems, funders concerned with
accountability should consider the creation of provider inventories, similar to that which exists for
providers of mental health services (the Inventory of Mental Health Organizations, National Institute of
Mental Health, 1983 and 1986). Such periodic surveys would enable comparisons of providers'
performance controlling for differences in provider characteristics. A survey developed by the U.S.
Department of Commerce, Bureau of the Census (1995) on behalf of the Interagency Council on the
Homeless (the National Survey of Homeless Assistance Providers and Clients) may serve as a good
beginning point for such a survey.

The major problem for providers will be collecting the information necessary to measure performance,
however it is measured (Huebner & Crosse, 1991). Clearly, standardization of information collection,

National Symposium on Homelessness Research

4-11

Making Homeless Programs Accountable to Consumers Funders and the Public

automation of information collection, and, in particular, explicit reporting requirements by government
funders, will drive the collection of performance data. Though challenging, streamlining data and
achieving unduplicated counts of consumers is doable (Friedman, 1998). A great deal of work remains,
however, before the multitude of service and funding systems are fully coordinated. For example one
administrator wondered how it was possible to report to multiple, and as many as fifteen or more, funders
(Harris, 1998).

Besides these data collection difficulties, an equally challenging quandary for both providers and funders
is that the homeless services system, is primarily reactive, and cannot always be appropriately
accountable for patterns of homeless service utilization. People may stay longer in shelters because the
supply of housing certificates or affordable housing shrinks, or more people may re-enter shelters
because of welfare reform. Thus, the performance of homeless providers is affected by significant
externalities that are beyond the control of the homeless providers, or their funders. This contingency
makes any assessment of homeless providers' "performance" necessarily tentative and provisional.

Accountability to the Public

Because public funders essentially represent the public, requiring accountability for funding expenditures
serves the public's interest. However, funders cannot just require reporting from providers, but must
make available to the public information regarding how their systems, or networks of providers, are
performing, what they cost, and what objectives they do or do not meet. In so doing, the public may be
more able to hold policymakers accountable for sound public policymaking and efficient administration
of programs.

Accountability to the Public: Research Strategies

Strategy

Methodology

Homeless System Performance

Services delivered and costs Effectiveness Efficiency

Program Innovations

Comparison of program types Costs/Effectiveness/Efficiency Pre-
Post comparisons

Policy Changes

Pre-Post comparisons Multiple Systems Analysis (Data
integration across systems, secondary impacts on health, welfare,
housing and criminal justice systems.)

The Congress, state legislatures, and their administrative departments are institutions, which through
their funding structures, can require local agents to report standardized information on services.
Unfortunately, there are fewer requirements that obligate federal agencies to make easily available
standardized, comprehensive measures of relative performance by jurisdiction. For example, while HUD
and HHS and other federal departments currently require providers to report the number of consumers
served, consumer characteristic information, and services received (i.e., through the Annual Performance
Report (APR), through the Projects for Assistance in Transition from Homelessness (PATH) and Health
Care for the Homeless (HCH) reporting requirements, and the Runaway and Homeless Youth (RHY)
reporting system), they less consistently require outcome information or jurisdiction level information
(which would require unduplication across the jurisdiction). The HUD APR does collect outcomes such
as housing stability and changes in income, and the Center for Mental Health Services (CMHS) does

4-12

National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

require outcomes data on persons served by PATH. These efforts will hopefully be further advanced by
the Government Performance and Results Act. However, from a public accountability stand point (a
system versus provider level of analysis), most Federal programs do not require jurisdiction-wide
aggregation of those measures on an unduplicated consumer basis. Thus, it is difficult for the public to
judge whether policies are having an intended effect (i.e., Are fewer people homeless? Are people
homeless for shorter periods of time? Do peoples' incomes and quality of life improve as a result of
program participation?). Policy can consequently be more often driven by anecdote, the exigencies of
funding constraints, and the ideological perspective of policy makers, rather than a reasoned discussion
and review of the evidence. One could argue that the inability to have institutionalized jurisdiction-wide
performance measurement results in public policy being unaccountable to consumers as well as the
general public.

This lack of performance information is particularly disconcerting given that many important and
national initiatives have been undertaken by state, local, and federal governments. Despite their value,
without information to substantiate efficiency and efficacy, good programs often remain demonstration
projects and are not realized on an appropriate scale. Similarly, failed policies can remain in place
because they suit the prerogatives of established interests, though they may have little evidentiary basis
for continuing.

Alternatively, some service integration strategies and some large demonstration projects have been
documented and there is much to be learned from them. Dennis, Cocozza and Steadman (1998) present
findings from 10 different systems integration projects which used different levels of evaluation
procedures, ranging from none at all to sophisticated quasi-experimental, outcome-oriented designs.
Some, such as the HUD Shelter Plus Care Program, have demonstrated significant improvements in the
lives of program participants in both service usage (e.g. engagement in needed treatment and reduced
hospital and jail use), and material well-being (e.g. increased income, employment, and housing stability)
(Fosburg et al., 1997). Similarly, the NIMH/CMHS McKinney Demonstrations showed a dramatic
improvement in residential stability resulting from increased collaboration between the participating
housing authorities and mental health centers. Only one project, the ACCESS Program, has built in
outcome measures at the consumer, program, and systems levels. Some of the improvements
demonstrated by these programs are very important, and because they have supporting evidence,
arguments can be advanced for their continuation, and they are less vulnerable to legislative or
departmental program cuts.

Cost-Benefit Analysis

Very little research has been published about the cost-effectiveness of services to homeless people.
Studies that have been published fall into two major groups: research on small groups of homeless
consumers (usually fewer than 100), and program evaluations which are usually completed by (or on
behalf of) service providers and/or government agencies that fund programs serving homeless people.
Research studies often use rigorous data collection strategies and powerful statistical tools, and results
are published in academic journals several years after services are provided. Program evaluations tend to
use routinely collected administrative data, have substantially larger sample sizes, and their results are
often reported quickly in order to support program planning and decision-making about ongoing funding.

As with any consumer level, provider level and systems level analysis, cost-benefit analysis uses
information that most homeless service providers have limited capacity to collect: consumer
demographics, service utilization, and outcomes for the same group of consumers over time or across
service settings or programs. Very few programs even use unique consumer identifiers, so they may not

National Symposium on Homelessness Research 4-13

Making Homeless Programs Accountable to Consumers Funders and the Public

have the capacity to determine how many intakes or bed nights are unique to individuals, or how many of
the people served at one site are also served later in the year at another program site. The kind of data
that providers do collect relates to the following program needs: (1) establishing consumers' eligibility
for services, (2) documenting service utilization for billing purposes, and (3) to a very limited extent,
documenting outcomes that are of interest to the source of funding for the program. While there is
clearly a need for more comprehensive data collection by providers, cost-benefit analysis can utilize a
variety of measures based on the kind of data that providers may already collect.

Ideally, cost-benefit analyses would compare the total costs and benefits of providing homelessness
interventions with the total costs and benefits of providing no interventions, or some other standard set of
services. This analysis requires measurement of costs in a wide range of systems, and we are not aware
of any study that synthesizes data from every relevant system to measure the costs of not addressing
homelessness at all. Instead, it is likely that we will need to patch together information from a variety of
sources and methodological approaches to draw conclusions about what service models "work" to reduce
homelessness and to identify both the costs and the savings benefits to consumers and to the public.
Cost-benefit analysis includes the following methods: cost effectiveness, before and after comparisons,
service utilization comparisons, waiting list comparisons, comparisons between groups, comparisons
between programs, multivariate analysis, and multiple systems analysis. All of these approaches can
provide valuable information about the relative costs of homelessness interventions.

Cost-Benefit Analysis

Strategy and Analysis Level

Description

Cost Effectiveness
(Consumer Level)

Measures the costs for providing a unit of service to an eligible
consumer.

Before and After Comparison
(Consumer Level)

Compares service utilization costs by homeless consumers before
entering program with costs after leaving program.

Service Utilization Comparison
(Consumer Level)

Compares service utilization costs by homeless consumers with
non-homeless consumers.

Waiting List Comparison
(Consumer Level)

Compares service utilization costs and benefits by currently
served consumers with eligible consumers on waiting list.

Programs Comparison
(Program Level)

Compares service utilization costs and benefits between two or
more of the same kind of programs or between programs that
offer different kinds of intervention.

Multiple Systems Analysis
(System Level)

Measures costs and benefits of services to consumers relative to
not providing those services using data from the homeless-ness,
housing, health care, mental health and substance abuse
treatment, criminal, and welfare and employment systems.

Cost Effectiveness. Some studies simply measure the costs for providing a unit of services to an eligible
person. If the costs appear to be "reasonable" and the projects appear to achieve desired outcomes for
most consumers, the report concludes that services are "cost effective" (Matulef et al., 1995). While not

4-14

National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

a complete picture of cost-effectiveness, this measure may be meaningful if a desired outcome is the
engagement of the project's target population. This is particularly true in the case of projects serving
consumers who have not consistently participated in treatment. It can also be a useful indicator of the
efficiency and effectiveness of program implementation in terms of evaluating such program activities as
filling vacancies, or providing outreach to maintain program capacity.

Before and After Comparison. Costs of services utilized by homeless individuals before they enter a
program are compared to costs and benefits during and after program participation. For example, the
evaluation of the Minnesota Supportive Housing Demonstration Program (Tilsen, 1998) found that
average monthly costs for a range of services, including hospitals, jails, state institutions, and income
support, were reduced from an average of $2,168 to $1,370 per month, resulting in annualized savings of
$1.7 million a year for 180 units of supportive housing. Changes in residential stability, consumer
functioning, and consumer satisfaction are also reported. Because some homeless people might have
achieved some improvements in functioning or reduced utilization of other services without program
assistance, it has been suggested that changes measured using this approach may be useful as an estimate
of the upper boundary of program impacts (Rosenheck et al., 1995).

Service Utilization Comparison. In a recent study which examined hospital discharge data from New
York City's public hospitals, Salit et al. (1998) found that homeless patients stayed 36 percent longer
than other patients, after adjustments were made for clinical and demographic characteristics. Rosenheck
and Seibyl (1998) reached similar conclusions after comparing a national study of the health service use
and costs for homeless and domiciled veterans hospitalized in psychiatric and substance abuse units at
VA medical centers. The authors found that 13.3 percent more money was spent serving homeless
veterans than domiciled veterans. Measurements of the costs associated with homelessness are one way
of identifying the savings that could be achieved by successful interventions. Ideally this information can
be linked to data from programs serving homeless people to compare the costs of programs that are
successfully targeting and retaining people with the same clinical and demographic characteristics.
Programs to prevent homelessness can use a similar approach by creating models to project what would
have happened to program participants if services had not been provided. The New York State
Department of Social Services (1990) used this method to estimate the cost effectiveness of programs
that intervened to prevent evictions, and estimated that the late stage eviction component of their
Homeless Prevention Program saves approximately $1 1.6 million in averted homeless costs.

Waiting List Comparison. Another strategy that has been discussed but not fully pursued is to compare
costs and benefits for program participants with those for homeless individuals who are eligible for the
program but on wait lists because of limited program capacity. Where participants are selected by
lottery, (as is often the case in housing for homeless people), there is de facto random selection into a
treatment group and a control group. Comparison between the service utilization costs and program
benefits between these groups may yield valuable cost-benefit data. While it would be very difficult to
track homeless individuals who do not receive services, information from public data systems such as
public hospitals and clinics, mental health services, and other systems of care could be used to gather
longitudinal data on wait list subjects.

Program Comparison. A number of research studies compare two or more programs which use
interventions that are based on different service models. For example, Wolff et al. (1997) compared
costs and outcomes for three types of case management after randomly assigning consumers to each
service model. The authors found that higher average costs for two assertive community treatment
approaches were associated with increases in financial assistance (vocational/educational, residential,
and income support) and decreases in costs for inpatient psychiatric services, when compared to less

National Symposium on Homelessness Research 4-15

Making Homeless Programs Accountable to Consumers Funders and the Public

intensive and less expensive brokered case management services. Dickey, Latimer, Powers, Gonzalez
and Goldfinger ( 1 997) compared two types of housing with services and found that treatment and case
management costs did not vary by housing type, but that one housing program was significantly more
costly than independent living arrangements, without producing significantly different outcomes.
Rosenheck et al. (1995) used multivariate analysis to assess relationships between specific treatment
elements and outcome measures in VA homeless programs. Using this approach, the researchers
measured the costs for determining a standardized amount of improvement for different outcomes
(housing stability, symptoms, employment), using different service strategies (e.g., case management,
residential treatment, and income supports). They found that the cost of residential treatment was three
to five times the cost of case management for achieving a standardized amount of improvement in
outcomes, but that the interventions were associated with improvements in different areas of functioning.
Residential treatment was associated in improvements in the number of days housed and days employed,
while case management was associated with improvements in days of substance abuse and psychological
distress. Income transfer payments were associated with improvements in days homeless but worse
outcomes in paid employment.

Multiple Systems Analysis. Because homeless people often face a number of additional problems, such
as mental illness and drug and alcohol addiction, it is important to compare costs from many different
service systems. These data include utilization of shelter, housing, and other "homeless" services;
utilization of health care, mental health and substance abuse treatment; utilization of welfare and
employment services; and involvement with the police and jail systems. For families, we need to also
consider costs of child protective services and foster care. We know anecdotally that effectively
stabilizing the lives of homeless people can prevent or reduce the costs of services in each of these
systems. A number of the program comparisons cited above (Wolff et al., 1997; Dickey et al., 1997;
Tilsen, 1998) combine data from several of these systems, but to date there have been no published
studies that have been successful in accessing and matching data from all of these systems.

Challenges. The limited availability of cost-benefit information is a result of a variety of challenges
frequently encountered during cost-benefit analyses. These challenges include: high attrition rates, small
sample sizes, imprecise measurement of service utilization costs, inconsistent data over time and across
systems, and lack of provider commitment to and resources for data collection. A description of the
extent of these challenges is followed by a description of strategies that providers can use to meet them
and conduct effective cost-benefit studies.

Attrition rates in most studies are very high, reflecting the instability in the lives of many homeless
people. In some studies plans to track participants over an extended time period are abandoned when
findings are compromised by high rates of attrition. After 12 months, Rosenheck et al. (1995) were able
to conduct follow-up interviews with only 37 percent of homeless veterans who had agreed to participate
in the study at entry into the program. Wolff et al. (1997) found that between 33 percent and 63 percent
of participants assigned to case management dropped out, and that higher rates of attrition in brokered
case management compared to assertive community treatment may have resulted in unknown bias that
compromised the study's conclusions. Attrition is particularly problematic if participation in data
collection is dependent upon participation in services, as is the case in most data collection by programs
that serve homeless people. Because our current research does a poor job of tracking outcomes for
homeless people who discontinue treatment, findings can be generalized only to those who are most
successfully engaged in services. Better outcomes for consumers are usually associated with more
consistent participation in services, but it is hard to tell if this is cause or effect. It is possible that both
participation and outcomes such as residential stability, employment, or improved quality of life, are
associated with other variables that are not identified upon intake. For example, people who experience

4-16 National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

substance abuse relapse problems are likely to discontinue participation in services and have worse
outcomes that are not included in study results because they drop out of data collection.

Another challenge for cost-benefit analysis is sample size. Sample sizes that are too small will not yield
statistically valid results. Consequently, it is often very difficult to identify statistically significant
differences between program outcomes, even when there appear to be changes in the expected direction.
Compounding this problem, observed changes are often small and progress for many homeless people is
unsteady and rarely linear. In addition, service utilization after intervention is often strongly correlated
with prior service utilization (Wolff et al., 1997). Large sample sizes would resolve these two problems,
because the larger the sample size the easier it is to detect small or non-linear changes and the easier it is
to control such variables as prior service utilization.

A third challenge to conducting cost-benefit analysis is the difficulties with using billing records data.
Public data systems that have been created for billing purposes usually report charges which may be
much higher than actual costs, while payment rates from Medicaid or other programs may be lower than
costs. Services which are not reimbursed (e.g. jail medical care) are often not recorded in a way that is
easy to assign costs. One partial solution is to use data systems to gather information about the types and
quantity of services used by consumers, and then use other budget information to get average costs for
each type of service. This is particularly appropriate when variability in the costs of other services, (e.g.,
regional variations in the cost of a hospital day), is not relevant to measuring the effectiveness of
different programs (Dickey et. al., 1997).

The inconsistent reliability of billing records is related to the wider problem of "messy data." People
who are homeless are often not identified consistently when they use services, and many will have more
than one "unique identifier" in public data systems. If it is not possible to gather data from all of these
systems, significant cost shifting may not be identified in the analysis. For example, a reduction in
hospital use may be a benefit, or may reflect increased rate of incarceration for study participants.
Another source of data problems is the changes in the data systems of public health departments,
hospitals and mental health systems data systems that has accompanied the recent transition to managed
health care. This often results in significant year-to-year differences in data quality, format, and
availability, making it extremely difficult to get consistent information about service utilization over
time.

Homeless service provider capacity and willingness to participate in data collection may also limit the
availability of data. Direct service providers have challenging jobs, are often required to use creative
strategies to engage consumers who may be resistant to the offer of services, and often deliver services in
unconventional settings. This leaves little time to fill out paperwork, particularly when providers do not
see analysis of the data they collect data collection as helping their front-line efforts. This problem can
be mitigated to some degree if the collected data is analyzed and given back to program staff quickly and
in a format that is useful to them and their consumers. Administrators can provide incentives for the
collection of data by proving a link between cost-benefit analysis and improvement in consumer
outcomes and/or in the acquisition of additional funding.

Because of the above challenges, powerful statistical techniques and a very significant investment of
resources are needed to achieve ideal levels of scientific validity and reliability. However, this sort of
research usually takes years to complete, requires resources outside of the reach of most homeless
programs, and the results may not be published until three to five years after the program intervention has
been tested. Homeless advocates, then, must be prepared to utilize a number of less thorough cost-
benefit analyses to develop an understanding of the savings represented by various approaches to
addressing homelessness. Fortunately, there are a variety of strategies advocates can use that will

National Symposium on Homelessness Research 4-17

Making Homeless Programs Accountable to Consumers Funders and the Public

increase the rigor of their cost-benefit analyses. Forging partnerships with providers in other service
systems, for example, can address the problem of attrition by facilitating longitudinal tracking of their
consumers. Utilizing the MIS programs discussed above can help standardize routine data collection and
increase sample size for studies that include multiple providers and multiple service systems. These MIS
systems can also facilitate speedy feedback from program administrators and funders that both providers
and consumers could use to measure and improve consumer outcomes.

The importance of system-wide cost-benefit analysis is evident when considering programs whose
consumers have multiple problems and utilize multiple programs. For example, those people who visit
public hospital emergency rooms 12 to 50 (or more) times a year and the visible homeless people in our
streets and parks tend to have similar characteristics — chronically homeless, out-of-treatment addicts,
out-of-treatment mentally ill, and often living with chronic health problems and at very high risk for
HIV/AIDS. As we move toward establishing new systems of accountability which measure outcomes
and cost-effectiveness, we need to be sure that we do not create fiscal or other incentives for programs to
"cream" and to exclude those most at risk of failure. For example, programs that require 60 days of
sobriety before intake may achieve better outcomes related to employment and housing stability, but may
be completely inaccessible to most of the homeless people who are seen in public hospital emergency
rooms or city doorways.

As described earlier, to get a complete picture of cost effectiveness, we need to look across systems and
funding streams (e.g., federal, state, and local, as well as "homeless," health care, criminal justice, and
welfare). However, program and funding decisions are almost never made from this global perspective.
For example, it is hard to convince a county mental health department to allocate funds for interventions
that will create savings in other systems by reducing entry into shelters, hospitals, or jails and that may
result in increased demand for the limited resources available within the mental health system.
Homelessness does not occur in isolation and so must not be addressed as an isolated phenomenon. The
need for cost-benefit analysis that integrates data from a variety of systems, then, reflects the need for
policies that bring providers from a wide number of systems together to solve homelessness.

Finally, cost-benefit analyses can provide powerful tools for homeless advocates in the policy arena.
Any intervention designed to reduce or end homelessness requires funding, and quantitative arguments
that a given intervention can save money relative to not investing in that intervention can go a long way
to obtaining that funding. The matter of funding is perhaps the clearest aspect of accountability to the
public whose taxes fund the vast majority of homeless programs and who has a vested interest in
eliminating homelessness.

Next Steps

The assessment of consumer needs, reporting of services, and the measurement of consumer outcomes
are where policy and practice meet. Policymakers need information to drive decisions such as the
allocation of resources and the design of programs, and practitioners need data to understand who they
are serving, how they serve them, and to what effect. Thus, information collection represents an
intersection of interests and around which there could be concerted effort to improve upon current
practice. Consumers, providers, funders, and the public, all stand to gain by a system of mutual
accountability that can be enabled by reasonable and accurate data collection.

At the most basic level, providers and consumers can be the keystone for such an effort through their
initiation or cooperation with the development and/or implementation of standardized information

4-18 National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

collection. Organizations of providers or "service systems" (i.e., local government) can foster such
standardization by establishing agreed upon protocols or through adoption of existing mechanisms for
collecting information. Service systems can use the goal of accountability as one way to encourage
participation in such arrangements. Local government can also demonstrate their conviction and value
for such efforts by supporting the functions of assessment, tracking and outcome assessment, financially
and materially through equipment and technical support.

Similarly, the federal government can support accountability for consumers, funders, and the public by
funding and even mandating the establishment of minimum data collection requirements. At a minimum,
homeless programs can begin to be accountable to the public if jurisdictions were required to report basic
information such as: unduplicated counts of consumers served, units of service by consumer type, and
direct (i.e., housing stability, reduced hospitalization, improved quality of life, even if just on a sample)
and indirect (i.e., rate of readmission) measures of service utilization. The extensive data collection that
has been part of the Department of Veteran Affairs national homeless program has clearly demonstrated
the possibility of generating higher levels of accountability on a national scale in integrated service
systems (Kasprow et al., 1997; Seibyl et al., 1997). If inducements to collect standardized information
were in place, local, state and federal government as well as consumer and provider advocacy groups and
other interested parties could exploit information technologies and establish monitoring systems. These
systems could be used to gauge demand for emergency shelter, and measure duration of shelter stays, rate
of shelter exit and return, and assessment of consumer satisfaction.

With these tools at hand, an evidentiary discussion of the merits of existing or proposed policies could
ensue. Perhaps even more importantly, the system of homeless services from a policy perspective can
become more proactive and apply such information technologies as an accountability check and as a
critical performance measurement for the larger social welfare and insurance systems. For example, if
welfare reform produces increases in shelter admission or longer shelter stays, homeless providers and
consumers would be in a position to prove it. If increases in the development of support housing units
yield increases in the rate of shelter exits, local governments can show it. If managed care of Medicaid
programs is leading to premature discharge of hospital patients, some of whom end up in the shelters,
regulators can prove it. In this way, the homeless system can become an accountability check on the
larger arena of public policy related to poverty.

Recommended Research Initiatives

• Develop new instruments that measure consumer outcomes, provider performance, and systems
effectiveness and efficiency. These instruments should be brief, reliable and valid so they can be
used by practitioners without interfering with their ability to meet their consumers' needs and at the
same time can provide useful evaluative data. Such instruments should capture a variety of data
including: performance variables that measure inputs (services provided), outputs (placements to
housing, tenure in housing, increases in income), ALOS (average length of stay), and organizational
characteristics (size, auspice, funding sources, staffing levels, ownership, revenues by source,
expenditure by category, etc.).

• Forge a closer relationship between providers and researchers so that provider-identified trends could
become the source of formal research projects.

• Develop techniques and guidelines for tracking the outcomes of consumers longitudinally. Protocols
should be established for sample sizes and periodicity of follow-up.

• Develop benchmarking measures for performance. These include ratios of inputs to outputs, which
may include cost-benefit analyses. A crucial component to these benchmarks is the development of a

National Symposium on Homelessness Research 4-19

Making Homeless Programs Accountable to Consumers Funders and the Public

more common understanding of what services and units of services mean in different settings so that

they can be more comparably measured. This common understanding should include input from

consumers, providers, funders, and researchers.

Conduct system-wide analysis that provides the "bigger" picture policy effectiveness to answer the

following questions: Do expenditures yield reductions in costs in other systems? Do broad policy

initiatives yield overall gains in housing stability, costs, etc.?

Devise creative strategies (e.g., data integration strategies, interagency task forces, or case reviews)

to use data from different systems that take different forms.

Adopt automated systems (e.g., software programs, or management information systems) more

widely in order to track consumers at the site of service delivery.

4-20 National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

References

Acosta, O. & Toro, P. A. (1999, in press). Let's Ask the Homeless People Themselves: A Needs
Assessment Based on a Probability Sample of Adults. American Journal of Community Psychology, 26.

Attkisson, C. C, & Greenfield, T. K. (1996). The Consumer Satisfaction Questionnaire (CSQ) Scales
and the Service Satisfaction Scale-30 (SSS-30). In L. I. Sederer & B. Dickey (Eds.), Outcomes
Assessment in Clinical Practice. Baltimore, MD: Williams and Wilkins.

Ball, F. J., & Havassy, B. E. (1984). A Survey of the Problems and Needs of Homeless Consumers of
Acute Psychiatric Services. Hospital & Community Psychiatry, 35, 917-921.

Culhane, D. P., Eldridge, D. L., & Metraux, S. (1999). Homeless Shelters Provider Performance.
Unpublished manuscript, University of Pennsylvania Center for Mental Health Policy and Services
Research.

Dennis, D. L., Cocozza, J. J., & Steadman, H. J. (1998). What Do We Know About Systems Integration
and Homelessness? Working Paper presented at the HHS Workshop on Exemplary Practices Addressing
Homelessness and Health Care Issues, Washington, D.C.

Derogatis, L. R., & Spencer, P. M. (1982). The Brief Symptom Index; Administration, Scoring and
Procedure Manual. Baltimore, MD: Johns Hopkins.

Dickey, B., Latimer, E., Powers, K., Gonzalez, O., & Goldfinger, S. (1997). Housing Costs for Adults
Who Are Mentally 111 and Formerly Homeless. The Journal of Mental Health Administration, 24: 291-
305.

Dohrenwend, B. P. (1976). Psychiatric Epidemiology Research Interview (PERI). New York: Columbia
University, Social Psychiatry Research Unit.

Fosburg, L. B., Locke, G. P., Peck, L. & Finkel, M. (1997). National Evaluation of the Shelter Plus
Care Program. Washington, DC: U. S. Department of Housing and Urban Development, October.

Friedman, D. H. (1998). Response. In D. P. Culhane & D. L. Eldridge (Co-presenters), Making
Homelessness Programs Accountable to Consumers, Funders and the Public. Symposium conducted at
the National Symposium on Homelessness Research, Arlington, VA. October.

Harris, R. (1998). Comment. In D. P. Culhane & D. L. Eldridge (Co-presenters), Making Homelessness
Programs Accountable to Consumers, Funders and the Public. Symposium conducted at the National
Symposium on Homelessness Research, Arlington, VA, October.

Herman, D. B., Stuening, E. L., & Barrow, S. M. (1994). Self-reported Needs for Help Among
Homeless Men and Women. Evaluation and Program Planning, 17: 249-256.

Huebner, R., & Crosse, S. (1991). Challenges in Evaluating a National Demonstration Program for
Homeless Persons with Alcohol and Other Drug Problems. In D. Rog (Ed.), New Directions for Program
Evaluation, 52: 33-46.

Kasprow, W. J., Rosenheck, R. A., & Chapdelaine, J. (1997). Health Care for Homeless Veterans
Programs: Tenth Progress Report. West Haven, CT: Northeast Program Evaluation Center.

National Symposium on Homelessness Research 4-21

Making Homeless Programs Accountable to Consumers Funders and the Public

Lehman, A. F. (1988). A Quality of Life Interview for the Chronically Mentally 111. Evaluation and
Program Planning, 11: 51-62.

Linn, L. S., & Gelberg, L. (1989). Priority of Basic Needs Among Homeless Adults. Social Psychiatry
and Psychiatric Epidemiology, 24: 23-29.

Matulef, M. L., Crosse, S. B., Dietz, S. K., Van Ryszin, G., Kiser, M. L., Puhl, L. M., & Ficke, R. C.
(1995). National Evaluation of the Supportive Housing Demonstration Program: Final Report.
Washington, D.C.: U. S. Department of Housing and Urban Development and the Office of Policy
Development and Research.

McLellan, A. T., Luborsky, L., Woody, G. E., & O'Brien, C. P. (1980). An Improved Diagnostic
Evaluation Instrument for Substance Abuse Patients: The Addiction Severity Index. Journal of Nervous
and Mental Disease, 168: 26-33.

Miesher, A., & Galanter, M. (1996). Shelter-Based Treatment of the Homeless Alcoholic. Journal of
Substance Abuse Treatment, 13: 135-40.

Moxley, D., & Freddolino, P. (1991). Needs of Homeless People Coping with Psychiatric Problems:
Findings from an Innovative Advocacy Project. Health and Social Work, 16: 19-26.

National Institute of Mental Health. (1983, 1986) The Inventory of Mental Health Organizations
(IMHO)for 1983 and 1986. Rockville, MD: NIMH, Survey and Reports Branch.

New York State Department of Social Services. (1 990). The Homelessness Prevention Program:
Outcomes and Effectiveness. New York, NY: Office of Program Planning, Analysis and Development
and Office of Shelter and Supported Housing Programs.

Robins, L. N., Helzer, J. E., Croughan, J. L., & Ratcliff, K. S. (1981). The National Institute of Mental
Health Diagnostic Interview Schedule: Its History, Characteristics and Validity. Archives of General
Psychiatry, 38: 381-389.

Rosenheck, R. A., & Lam, J. (1997a). Consumer and Site Characteristics as Barriers to Service Use by
Homeless Persons with Serious Mental Illness. Psychiatric Services, 48: 387-390.

Rosenheck, R. A., & Lam, J. (1997b). Homeless Mentally 111 Clients' and Providers' Perceptions of
Service Needs and Clients' Use of Services. Psychiatric Services, 48: 381-386.

Rosenheck, R. A., & Seibyl, C. L. (1998). Homelessness: Health Service Use and Related Costs.
Medical Care, 36: 1256-1264.

Rosenheck, R. A., Leda, C, & Gallup, P.G. (1992). Program Design and Clinical Operation of Two
National VA Programs for Homeless Mentally 111 Veterans. New England Journal of Public Policy, 8:
315-337.

Rosenheck, R. A., Wilson, N., & Meterko, M. (1997). Consumer Satisfaction with Inpatient Mental
Health Treatment: Influence of Patient and Hospital Factors. Psychiatric Services, 48: 1553-1561.

Rosenheck, R., Frisman, L., & Gallup, P. (1995). Effectiveness and Cost of Specific Treatment
Elements in a Program for Homeless Mentally 111 Veterans. Psychiatric Services 46: 1 131-1 139.

4-22 National Symposium on Homelessness Research

Making Homeless Programs Accountable to Consumers Funders and the Public

Salit, S. A., Kuhn, E. M., Hartz, A. J., Vu, J. M. & Mosso, A. L. (1998). Hospitalization Costs
Associated with Homelessness in New York City. New England Journal of Medicine, 338, 1734-1740.

Seibyl, C. L., Rosenheck, R. A., Medak, S., & Corwel, L. (1997). The Eighth Progress Report on the
Domiciliary Care for Homeless Veterans Program. West Haven, CT: Northeast Program Evaluation
Center.

Tilsen, T. (1998). Minnesota Supportive Housing Demonstration Program: One Year Evaluation
Report. New York, NY: Corporation for Supportive Housing.

U. S. Department of Commerce, Bureau of the Census. (1995). National Survey of Homeless Assistance
Providers and Clients. Survey designed for 12 Federal agencies under the auspices of the Interagency
Council on the Homeless, Washington, D.C.

Wolff, N., Helminiak, T. W., Morse, G. A., Calsyn, R. J., Klinkenberg, W. D., & Trusty, M. L. (1997).
Cost-Effectiveness Evaluation of Three Approaches to Case Management for Homeless Mentally 111
Clients. American Journal of Psychiatry, 754:341-348.

National Symposium on Homelessness Research 4-23

Giving Voice to Homeless People in
Policy, Practice and Research

by
Nicole Glasser

Abstract

Consumer involvement in programs that serve homeless people has been growing in the past ten to
fifteen years. There is a growing body of literature that supports the benefits of consumer involvement
on the programmatic, policy, and administrative levels. Consumer empowerment ranges from
participation in a community meeting or on an advisory board, to hiring consumer staff, to completely
consumer-run programs and organizations.

While there is resistance within any system to hand over power to a stigmatized group, once done, the
system may find that it has higher quality and more responsive services. Research finds that consumers
can perform as well as non-consumer staff and are especially skilled at engaging potential clients.
Within consumer-run organizations, the focus of service delivery is on choice, dignity and respect.
There are a number of things that federal, state and local governments can do to encourage consumer
involvement in decision-making, staff hiring, and the creation and survival of consumer-run
organizations.

Lessons for Practitioners, Policy Makers, and Researchers

• Organizations and agencies must plan for consumer involvement carefully. Through allocation of
adequate resources and education and preparation of non-consumer staff, the organization will be
laying the groundwork for true empowerment.

• The concept of choice and tailoring assistance to individual needs is central to the success of
consumer-run programs. They are indispensable to any program that truly serves its constituents.

• Research finds that formerly homeless consumers employed as staff, including those with serious
mental illness and persons in recovery from substance abuse, can perform as well as non-consumer
staff and may be especially skilled at engaging other homeless persons in services and treatment.

• Programs that incorporate consumer involvement tend to be more "user-friendly" or "consumer-
friendly" than agencies with no consumer involvement.

• Consumer-run organizations may be more able and willing to "do what it takes" to serve their
clients. In practice this might mean doing system advocacy, offering new types of services, and/or
having to find more funding.

• Everyone benefits with consumer involvement: providers may increase the quality and effectiveness
of their services; consumers become empowered through employment, advocacy and helping their
peers; and clients learn the value of peer support.

National Symposium on Homelessness Research

5-1

Giving Voice to Homeless People in Policy, Practice and Research

Having personally walked many high roads and low roads as a consumer of mental health and homeless
services, nothing makes more sense to me than allowing clients, or consumers of services, to have a
greater say in their services — from the direct provision of services, to policy, administration and
evaluation. Who, after all, knows better what they need and want but consumers themselves? Research
has, indeed, found that homeless consumers are eager to define their goals and clarify their support needs
(Camardese & Youngman, 1996). But due to the stigma associated with homelessness, which is greater
if one happens to be mentally ill and homeless, the public and providers have had a tendency to assume
consumers do not know what they need, or that what they want is not 'clinically' appropriate.

Housing and services for people who are homeless have become more "user-friendly" as systems and
programs involve people who are homeless or formerly homeless in decisions about the services they
receive. For years, substance abuse treatment providers have employed persons with addictive disorders
and rehabilitative agencies have assisted persons with various disabilities to find and maintain
employment. With the passage of the Americans with Disabilities Act in 1990, mental health agencies
have made similar efforts to employ persons with serious mental illness marking an important advance in
the field of mental health care (Fisk, et al., in press).

Homeless people do not have a long history of organized advocacy efforts on their own behalf. The
larger self-help or consumer empowerment movement, a movement where individuals organized into
groups to help one another, has come a long way since its roots some 30 years ago. But over the past
decade, this movement has begun to really make its presence felt among programs for homeless persons.
Among mental health consumers, for example, the early period of the self-help movement was a
backlash against what consumers saw as an authoritarian and abusive psychiatric treatment system.
Former patients banded together into self-help and advocacy groups to heal from the damages sustained
while in "treatment," and to change the system. Some early groups felt the only way to really help each
other was through separate, peer-run services.

More recently, the mental health field has grown rich with self-help groups and consumer-run programs
which, rather than competing with professionally run programs, are reaching out to a population that
professionals have largely left alone — people who are homeless and mentally ill. In many cases, they are
working cooperatively with professionals and/or are funded by public mental health agencies. Instead of
letting "the system" off the hook for not providing adequate services, many of these programs are
involved in advocacy efforts to make the system more responsive (Long, 1988). Because of this
movement, much of the literature on consumer 1 involvement addresses homeless persons with serious
mental illness, who account for approximately one-third of the total homeless population (Federal Task
Force on Homelessness and Mental Illness, 1992).

The National Association of State Mental Health Program Directors (NASMHPD) recognized that
mental health consumers have a unique contribution to make to the improvement of the quality of mental
health services in many arenas of the service delivery system. In their policy statement, NASMHPD said
that the contribution of consumers "should be valued and sought in areas of program development,
policy formation, program evaluation, quality assurance, system designs, education of mental health
service providers, and the provision of direct services (employees of the provider system). In order to
maximize their potential contributions, their involvement should be supported in ways that promote

For the purposes of this paper, "consumer" will mean any person who has experienced being homeless. For clarity's sake,
when I use "clients" I will be specifically talking about individuals receiving services from a particular organization, program or
agency.

5-2 National Symposium on Homelessness Research

Giving Voice to Homeless People in Policy, Practice and Research

dignity, respect, acceptance, integration, and choice. Support provided should include whatever
financial, educational, or social assistance is required to enable their participation" (Wilson, 1990).

When consumers have the opportunity to be involved and have a voice in the organizations that serve
them, either through decision-making/policy involvement or employment, everyone wins: service
recipients, agency staff, the programs designed to help homeless people, and the systems in which they
operate.

Why Consumer Involvement Matters

What can happen when providers overlook the importance of consumer input is that many will refuse
services or treatment outright due to lack of choices. The dehumanization and depersonalization that can
happen while receiving services can make what is already a bad situation, intolerable. Not only do
consumers experience a lack of dignity and respect from providers, but they feel that many of these
agencies do not meet their needs. And many do not. At best, traditional services tend to treat people in a
regimented and impersonal manner (Howie the Harp, 1988). At worst, they are coercive, lacking dignity
and without opportunity for self-determination (Van Tosh, 1994).

The phrase "treatment-resistant" is often used to describe homeless persons who refuse mental health
treatment and other services. But there are often good reasons for the refusal to accept assistance. From
the perspective of homeless people, the services that are offered, and in some cases forced upon them,
may be completely undesirable and inappropriate. At other times they may not be enough.

The concept of choice is central to the success of consumer-run programs and is an indispensable part of
any program that truly serves its clients. Consumer-run programs have found that when these "resistors"
of traditional services are offered services and choices by peer/consumer providers, in a non-coercive,
voluntary environment, many of them become cooperative and eager to turn their lives around.
Everyone benefits with consumer involvement: providers have a chance to increase the quality of
services; consumers can step up to empowerment through employment and helping their peers; and
clients can learn the value of peer support.

Project OATS (Outreach, Advocacy and Training Services for the Mentally 111 Homeless), an entirely
consumer-run organization, is a perfect example of peer support at its best. Laura Van Tosh, former
Project OATS Director, tells of her experience doing street outreach with Mr. Smith (not his real name).
It reveals the type of commitment consumers, and consumer-operated programs make to help consumers
in need. In part, she writes:

In repeated, informal contacts with Mr. Smith I interacted with him as a peer, not as a
"professional " relating to a "client ". This approach helped to gain his trust because we
interacted as equals. For example, I sat next to him on the ground. I helped him with
immediate needs on the streets like obtaining plastic bags to hold his belongings. I
accompanied him sometimes for hours at a time during his efforts to obtain assistance
from the system. I was available to assist him 24 hours a day, seven days a week. . .
Although it was my belief that his most immediate need was housing, I respect his
judgment of which area of his life should be addressed first. . . he trusted me to advocate
on his behalf, and my commitment to stand by him was an important part of his decision
to seek help " (Van Tosh, 1 990).

National Symposium on Homelessness Research 5-3

Giving Voice to Homeless People in Policy, Practice and Research

Mr. Smith, after 14 years of falling through the cracks of the traditional service system and being
homeless on and off, is now living in supervised housing and obtaining case management services. It
should also be noted that, at the time, Ms. Van Tosh was not an outreach worker for Project OATS, but
the Project Director. Nevertheless, given the opportunity to connect with a potential client, she did not
let her formal job duties deter her from helping this individual. Such is the flexibility and lack of top
down structure inherent in many consumer-run programs.

In a similar example, Laura Van Tosh writes about another homeless individual:

"David (not his real name), a homeless man, has suffered from severe mental illness for
over 10 years. When I first met David, he was withdrawn, depressed and incoherent. He
was also living on the cold streets in the city. At first he would not communicate with
me, but over a period of a few days and nights he began to speak to me. Our
"conversations " consisted of my listening to bizarre stories of situations he had been in.
My simply being with him and listening meant something to David, for he continued to
talk to me each day I stopped by to see him. He understood my compassion and desire to
help him.

Since I, too, had been homeless and mentally ill, I knew that it mattered whether or not
someone took the time to talk to David. I told David that I also had been without a place
to live for a while and also had been hospitalized for mental illness. At first he didn 't
believe me, but after I showed him the medication I had in my purse, he did. And he
smiled. Suddenly I had gained the trust of David and his willingness to try to improve
his life. Through our many hours of conversations, David began to understand what
empowerment meant. He learned that helping himself was an integral part of good
health and that only he could truly help himself. My help was merely a step in the
empowerment process" (Van Tosh, 1988).

Soon David had secured housing, rehabilitation support, and part-time employment. David became a
valuable member of a consumer-run project. The peer-support process came full circle when David was
able to assist a homeless person who wanted services. Moreover, David's record of recidivism, which
was costly to the system, has been supplanted by stability in the community.

These examples stand in sharp contrast to the structure of many service programs that homeless people
need. Professionally-driven services are often office-centered and appointment-driven. They put clients
on waiting lists for continuing service and require clients to fit into the routines of structured activities.
They focus on clinical rather than survival needs. Moreover, many service providers are often reluctant
to serve homeless people due to reimbursement issues or stigma (Long, 1988). Clearly, consumer-run
services have the potential to fill some very large gaps in the current service system for people who are
homeless.

Literature Review and Program Examples

The research literature on the involvement and roles of formerly homeless consumers in policy, research
and service delivery is scant. What is there, is drawn largely from the area of mental health where
researchers have examined the effectiveness of consumer staff (Dixon, Krauss, & Lehman 1994;

5-4 National Symposium on Homelessness Research

Giving Voice to Homeless People in Policy, Practice and Research

Solomon & Draine 1995; Fisk et al., in press; Chinman et al., in press), the impact of honoring consumer
preferences for housing on outcomes for residential stability (e.g., Goldfinger & Schutt 1996), and efforts
to empower consumers (Cohen 1994; Ware et al., 1992).

Despite the lack of more extensive research in this area, there is a substantial body of descriptive
material in the form of articles, reports, and technical assistance manuals that provides the base for
knowledge in this new and developing area. What follows is a review of the available literature as it
addresses many levels of consumer involvement, from creating consumer advisory boards, to hiring
consumer staff to developing consumer-run organizations. Additional evaluation and outcome-based
research are needed to confirm and refine the practices and models that are recommended from the field.

Consumer Advisory Boards and Consumers on Advisory Boards

One of the first efforts an agency might make to develop empowerment-oriented approaches is to create
a consumer advisory board. Ideally, such an effort will emphasize the shifting of power and resources to
the consumers of services. By giving clients a voice in policy formation, a consumer advisory board is a
logical extension to empowerment. But groups aimed at increasing client power are likely to encounter
organizational resistance, particularly when clients are members of a stigmatized group. Researchers
have found that it is one thing for agency staff to support empowerment as an abstract goal but quite
another to shift power to clients, away from themselves. This often feels problematic to staff (Cohen,
1994). Moreover, many attempts to empower clients will fall short of transferring power to consumers,
yet administrators and staff will report that they now "empower" their consumers (Salzer, 1997).

One way to overcome professional resistance (due to ignorance and stigma associated with being
homeless) is through staff training and education. The most effective training will have consumers
involved as part of the training staff. Unless managers include consumers in these activities, their
presentations will be limited to their own perspective. Joint leadership between consumer staff and non-
consumer staff in education and training efforts will also demonstrate an important partnership between
the two groups (Fisk, et al., in press). Non-consumer staff needs to be adequately prepared for the
shifting of power to consumers before involving consumers.

Once an organization makes a commitment to involve consumers by educating and preparing staff and
creating a mechanism for input (i.e., consumer advisory board or adding consumers to its board),
administrators need to:

• ensure real response and tangible outcomes to consumer input, suggestions and complaints;

• avoid "tokenism;"

• allocate adequate staff time for consumer recruitment and follow-up; and

• provide financial stipends to consumers willing to sit on boards and committees.

Cohen's study of a consumer advisory board in a New England agency serving homeless and low-
income clients found that the inadequate preparation of staff and lack of real response to consumer
complaints resulted in consumer interest in the group falling off quickly. The agency also failed to
appoint a staff person who would be responsible for contacting specific individuals for recruitment and
follow-up.

Tokenism, defined as one person on a board or committee to represent an entire class of people, is
probably the most common error committed by well-intentioned organizations (Van Tosh, 1993; Wilson,

National Symposium on Homelessness Research 5-5

Giving Voice to Homeless People in Policy, Practice and Research

1990). Limiting consumer involvement on boards or committees to one person means that the consumer
has no natural allies on the committee, making involvement, an intimidating or potentially threatening
experience. Lastly, given that staff are paid for their time when they formulate policy and make
administrative decisions, so too, must consumers be compensated to being involved in such matters.
Consumers are the experts when it comes to their needs and desires. Financial compensation is an
absolute necessity for consumers sitting on policy boards and other administrative committees.

Surveying clients is another good way to include consumer input in program implementation and
evaluation. These surveys are an important step in the development and maintenance of "quality"
services and programs (Van Tosh, 1993). But using surveys to substitute for true consumer involvement
is not meaningful empowerment. They must be used in conjunction with other types of consumer
involvement - on the programmatic, policy and administration levels. Moreover, true consumer
empowerment would also involve consumers in interpreting the input and feedback on the development
of interventions that result from the input. Anything less than participation in the whole process is not
empowerment (Salzer, 1997).

Below are three examples of how consumers are involved in advisory groups or on the boards of national
and local organizations.

National Coalition for the Homeless was founded in 1982 by local and state homeless
coalitions who felt the need for a national voice to address issues related to
homelessness and poverty. The organization, which has a total of eight staff persons,
employs two formerly homeless individuals, and mandates that 30% of their policy-
making board be consumers. In addition to offering technical and support services to
local and state homeless groups, the Coalition trains consumers on how to get involved
in HUD 's Continuum of Care planning process and general advocacy skills, including
how to be an effective board member. "We feel strongly that consumers must lead the
way" states Mary Ann Gleason, Executive Director of the Coalition. The organization
recently demonstrated this commitment by raising funds to provide scholarships for
nearly 100 consumers to attend the Coalition 's annual meeting.

St. Francis House in Boston is a professionally-run day shelter open from 7:30 AM to 3
PM every day. The day shelter offers an array of services to 150-1 70 "guests " each day.
The Guest Advisory Council was the idea of employees at the shelter who asked, "how
do we know what our guests need here? " and decided the only proper way to answer
that question was to ask the guests themselves. The Council is an open weekly forum in
which guests can voice any issue they might have. The group is facilitated by staff,
although Harrison Fowlkes, one of the facilitators, explains that they encourage guests
to take charge as much as possible.

When the Council meetings first started there were a lot of complaints about staff, the
food and clothing distribution, "but over time the group has begun to take on the flavor
of a mini-political arena " states Harrison. Because the shelter has been able to respond
in tangible ways to guest concerns, the Council is now able to look beyond their
individual situations and into issues affecting them as a community. Guests are
currently planning to be involved in a march and rally in Boston for more affordable
housing because, as Harrison notes, many guests have jobs but still cannot afford the
high price of rent in Boston.

5-6 National Symposium on Homelessness Research

Giving Voice to Homeless People in Policy, Practice and Research

The Central Massachusetts Housing Alliance is committed to helping the communities
of Greater Worcester and Worcester County respond to the needs of homeless, and near
homeless, people by supporting prevention programs, ensuring the availability of high
quality and appropriate sheltering and support services, working to increase the supply
of affordable housing, and empowering people through education. The Alliance involves
consumers at a policy level by encouraging homeless families to join local and state task
forces and committees. They also advocate for consumer representation in the
Continuum of Care planning process. They are committed to having consumers on their
Board of Directors even though it has been difficult for consumers to stay involved for
extended periods of time. The Alliance 's sub-committees, such as welfare reform and the
emergency assistance campaign, are totally guided by consumers (Farrell, personal
communication, 1999).

Consumers as Staff

The research to date suggests that consumers can make a unique and valuable contribution as program
and agency staff. This is particularly the case when agencies are trying to engage homeless persons who
have serious mental illnesses and/or substance abuse problems, or multi-problem homeless families.
Consumers working as staff possess experiences and characteristics that enhance their ability to provide
services to individuals who are homeless (Van Tosh, 1993; Fisk et al., in press; Dixon, Krauss, Lehman
1994; Solomon et al., 1994; Solomon & Draine, 1995; Chinman, Lam, Davidson, Rosenheck, under
review). In Working For a Change (Van Tosh, 1993) describes some of the unique characteristics of
consumer staff, including:

• Systems Knowledge - Persons who are currently receiving services, or who have previously
received services, are intimately familiar with many aspects of treatment, quality of care, agencies,
service models, housing opportunities and other information.

• Street Smart - They can provide street knowledge and understand the nuances intrinsic to the
outreach and engagement processes. For example, they are extremely knowledgeable of the
locations where persons who are currently homeless tend to congregate.

• Developing Alternative Approaches - Consumer workers are amenable to the exploration of
alternative service approaches because they have been homeless themselves and know how difficult
it can sometimes be to access services.

• Flexibility and Patience - Having "been there," consumer workers often know when flexibility and
patience is called for when providing time-intensive services.

• Responsiveness and Creativity - Consumer workers can be creative in developing solutions based
on client-expressed preferences and needs.

• Team Work - Consumer workers have a keen understanding of how teamwork is needed to provide
services to homeless persons with disabilities.

• Understands Basic Needs/Preferences - Consumer workers have been through similar experiences
while homeless and connect with others based on their common shared experiences. They can
identify with a client's need for a shower, locating a food source and bathroom facilities, safety
issues and knowledge of shelters. Often not viewed as essential skills by traditional providers,
workers who can help meet these basic requests foster the process of engagement.

• Engagement/Peer Support - Frequently, workers know persons who are homeless. They have an
already established rapport that is key to the engagement process. Part of this rapport is a shared

National Symposium on Homelessness Research 5-7

Giving Voice to Homeless People in Policy, Practice and Research

understanding of what it means to be homeless, and the resulting anger, frustration and feelings of
despair.

• Positive Role Modeling - Workers who have experienced the trauma of homelessness and are now
gainfully employed bring a certain inspiration to others, especially among persons who are homeless.
Having a positive role model can promote healing and well-being. It can also raise the level of
optimism toward recovery. Positive role modeling can have an overwhelmingly positive impact on
individuals, programs and systems.

• Fighting Stigma - Consumer workers are a major force in the elimination of stigma and
discrimination. Stigma in our society continues to plague the efficacy of responses to homelessness
and mental illness. Stigma, in its most virulent form, can impact the development of housing
opportunities and other services required to end homelessness.

Other unique characteristics of consumer staff include the fact that consumer workers are more tolerant
of unusual behavior, do not maintain a rigid distance from the people they serve, and show more
empathy for individuals' struggles. Employing consumers as staff can increase the sensitivity of non-
consumer staff to their clients, educate co-workers, can help to locate hard-to-find individuals and to
devise creative strategies to engage homeless persons who are resistant to services. Consumers as staff
have also shown a special ability to sensitively relate to and help solve problems clients face, identify
with client issues and offer coping strategies, and overcome obstacles with information and referral due
to their personal experience receiving services and facing these obstacles.

But as Laura Van Tosh warns, "Consumer involvement carries with it certain risks and must be done in a
thoughtful manner. When the involvement is implemented correctly, such involvement greatly enhances
the quality of services the patients receive." (Van Tosh, 1993). Any agency hiring consumer staff must
be adequately prepared for the commitment of hiring consumer staff.

Newly hired consumer staff are faced immediately with three challenging issues: disclosure of consumer
status, client-staff boundaries, and workplace discrimination (Fisk et al., in press). Due to the stigma
associated with having been homeless, disclosure of consumer status to non-consumer staff and clients is
an important issue for the consumer and his or her supervisor to discuss in advance. How does the
consumer wish to be known? Does he or she want to disclose themselves or do they mind being
identified by others. Disclosure must be carefully and creatively timed and will vary from one situation
to the next. As a general rule, it is suggested that disclosure not happen until one has proven his or her
ability to do the job.

Second, client-staff boundaries can be a source of stress for consumer staff especially if they are a former
client with the agency. This change can be hard for non-consumer staff and clinicians as well. Other
difficulties include having friends who are still clients, not feeling competent enough to do the job as a
former client, and other clients wanting to develop a personal relationship with the consumer staff
person. Lastly, and unfortunately, it can be quite common for disclosed consumer staff to face some sort
of discrimination - whether overt or subtle. Non-consumer staff has been known to treat consumer staff
differently, with less respect, than other co-workers.

In order to help the agency and consumer staff to overcome these complications, it is important that
administrators actively support unit-based or agency-wide implementation of a number of concrete
strategies for encouraging consumer employment. These are: (1) education and training of non-
consumer staff, (2) increased individual supervision for consumer staff, and (3) paying special attention

5-8 National Symposium on Homelessness Research

Giving Voice to Homeless People in Policy, Practice and Research

to the need to offer reasonable accommodation (ADA) or otherwise modify work responsibilities to meet
the needs of consumer staff with disabilities (Fisk et al., under review).

While professional staff working in programs may have the ability to connect in a meaningful way with
clients, they cannot replace the sense of "having been there" which consumer staff can provide.
Especially for clients who have had negative experiences in the service system, many of whom have
given up on getting help or are unable to trust, consumer/peer staff might mean the difference between
getting off the streets and recovering or never getting off the streets and never recovering. In the
homeless services industry, where so much effort is put into finding ways to reach people who are "help-
resistant," I wonder why there are not more consumer-operated and/or staffed street outreach programs.

Below are two examples of programs that employ consumers as staff.

Vita Nueva, a Shelter Plus Care housing program in Arizona, is a program of Compass
Health Care, a large health care facility in Tucson, Arizona. In existence for more than
five years, the program serves 44 women and men. The 22 women in the program are in
early recovery from addiction and have dependent children. All the women work
including a few women who are dually diagnosed. They pay 30% of their income to rent.
Nora Stark, Program Coordinator, is a formerly homeless mental health consumer who
has hired two former clients of Vita Nueva women 's program, one as Facility Manager,
and another as a case manager. Residents meet about every six weeks to, as Stark
explains, "go over the rules, regulations and expectations we have for them. If there is
, an item that is not working for them we discuss it and then vote on it " Residents can
vote to change such things as their own curfews, their children's curfews, swimming
pool hours, and the laundry room rotation schedule.

The McCormick Institute's Center for Social Policy at the University of
Massachusetts-Boston has a central computer server connecting shelters across the
state to a common computer system. "So policies formulated from this information will
be based on real people who have shared information about themselves with their case
workers, " explains Donna Haig Friedman, Director of the Center. In setting up this
system, privacy protection was a major issue. Consumers were engaged and paid to
participate in setting up the privacy protections. They are also a part of the statewide
steering committee. Consumers "advise us on privacy protections and have played a
major role in developing our information security system, " states Friedman.

Consumer staff also plan and co-lead forums where case managers are trained in
sensitive interviewing and in privacy protection. Recently, two consumer staff presented
at a national conference on the role of consumers in data collection and analysis. The
two consumers are writing a paper on consumer involvement in this project and one of
them has developed a focus group module to inform and empower shelter residents.

In another research project at the Center, four of the researchers are woman with
children who have been homeless. The study will survey families on the brink of
homelessness to find out what it would take to prevent them from becoming homeless.
"The women really knew what questions needed to be asked and how to sensitively ask
them, due to their awareness of the particular realities of the families ' lives when in this
situation, " states Friedman. "The consumers provided something very important to the

National Symposium on Homelessness Research 5-9

Giving Voice to Homeless People in Policy, Practice and Research

project. They also put a human face on the numbers. " The Center does not pre-assign
roles to consumers. "Each person is a very rich, complex person with lots of
experiences. It is unfair to pigeon-hole them due to just one of these experiences. "

Consumer-Run Programs and Organizations

Consumer-run programs for homeless people offer consumers a sense of belonging and an opportunity
for growth. Consumer-run programs are empowering, offering staff and participants a wealth of
information and experience. These programs show participating consumers that they can function
independently and with dignity. The empowerment aspect of these programs goes beyond the staff to the
people served. Consumer-run programs often cost-effective and can provide an oversight or quality
control function for the systems in which they operate (Van Tosh, 1988).

Because consumers have had personal experience in the service system — getting or trying to get
services — when they put together their own service organization, they try hard to tailor the system to the
client's needs rather than the client's needs to the system (Van Tosh, 1990). Flexibility is key. It might
mean allowing consumers the dignity to make mistakes. Instead of telling clients "no" or "we can't do
that here," consumer-run programs try to find creative ways to fulfill those needs.

In practice this might mean doing system advocacy, offering new types of services, or having to find
specialized funding for something no one else offers. When Project OATS in Pennsylvania, a consumer-
run organization, was finding it difficult to locate adequate housing resources for clients they decided to
do some system advocacy. They organized a "sleepout" to encourage the state of Pennsylvania to
develop more housing for people who are homeless and have mental illnesses. The "sleepout" and
related activities helped secure $5 million for residential programs for homeless persons with serious
mental illnesses in Pennsylvania. When Project OATS identified a need for training and employment for
homeless persons, they raised additional funds for the new project, ACT NOW.

The key principles of consumer-operated organizations as follows (Mowbray, Chamberlain, Jennings, &
Reed, 1984):

• The service must provide help with needs as defined by clients.

• Participation in the service must be completely voluntary.

• Clients must be able to choose to participate in some aspects of the service without being required to
participate in others.

• Help is provided by the clients of the service to one another and may also be provided by others as
selected by the clients. The ability to give help is seen as a human attribute and not something
acquired by education or professional degree.

• Overall direction of the service, including responsibility for financial and policy decisions, is in the
hand of the service recipients.

• The responsibility of the service is to the client, and not to relatives, other providers or funding
agencies. Information about the client must not be transmitted to any other party without the consent
of the client, and such information must be available to the client.

These principles show a great sensitivity to the issue of consumer control, an important issue for people
who, while homeless, had no control over such basic decisions as where they were going to sleep, what

5-10 National Symposium on Homelessness Research

Giving Voice to Homeless People in Policy, Practice and Research

they were going to eat, or when they could take a shower (Long, 1988). The following examples of
consumer-run programs illustrate many of these principles.

National Union for the Homeless was founded in 1985 by three homeless men in
Philadelphia, Pennsylvania. The organization was started as an organized response to a
drop-in center that was not consumer-friendly. Through successful media coverage of
the demonstration, the seeds for the National Union for the Homeless were sown.
Following the demonstration, a Philadelphia clergyman offered them a facility to run
their own shelter. With the support of a local provider who wrote a grant proposal for
them, the group received $23,000 to operate the shelter. "The men vowed that this
shelter would be different, " states Leona Smith, current President of the National Union
for the Homeless. "What really set it apart was the fact that they focused on advocacy
and social and political change. "

One of their first political victories was winning the right to vote for homeless people in
Philadelphia in J 985. In J 986 they held their first national conference, where some
3, 000 clergy, elected officials, homeless people, and unions came together to elect an
executive director for the emerging organization. In 1989, they started the national
"Housing Now " movement to challenge governments nation-wide to provide housing for
homeless people. Out of this struggle, the Union founded several consumer-run housing
programs. Three of these programs are currently operating: Dignity Housing West in
Oakland, California; Up and Out Housing in Minneapolis, Minnesota; and Dignity
Housing East in Philadelphia. All three programs offer housing opportunities, job
opportunities, home ownership and life skills services. The Union is also involved in
doing public education and has a professionally-produced video entitled "Take Over, "
funded in part by Bruce Springstein and Michael Moore, that is shown every year on
PBS television.

The PS Project in Parker sburg, West Virginia, started in 1994 as a consumer-run
support group. "But from the very first meeting what kept being brought up was the lack
of supportive housing. " explains Jackie Scott, Director of the program. The only options
people had were groups homes where their whole life would be controlled or
independent living with no supports. One and a half years later, the PS Project became
a consumer-run residence for homeless persons with serious mental illness. The house,
which can accommodate eight people, has no staff other than Scott who oversees the
finances of the project and does not provide any mental health services. Ten hours per
month of volunteer work is required of each resident to maintain the residence.
Residents also help each other with daily living skills, plan community and other fun
events, and encourage each other to prepare for independent living.

INCube. Another innovative idea that has arisen in response to the need for more
consumer-run organizations is the creation of organizations whose goal is to help other
consumer-run projects get off the ground. One such example is INCube, a not-for-profit
agency in New York City whose purpose is to "incubate " consumer-run businesses and
non-profit service organizations. Since its inception in 1988, INCube has assisted more
than 80 consumer-run businesses to provide full or part-time employment for persons
with serious mental illness. Several of these new projects are focused on homeless
people, both families and single adults. With 1 4 paid staff and funding from the state

National Symposium on Homelessness Research 5-1 1

Giving Voice to Homeless People in Policy, Practice and Research

and city departments of mental health as well as foundations, INCube is completely
consumer-run.

One program supported by INCube is INCA Housing. INCA Housing is a consumer-run
50-unit scattered site housing program for homeless families and individuals in the
Bronx. Run directly by consumers of mental health services, INCA 's highly trained
managers assist clients with public benefits, finding and keeping housing, interfacing
with treatment teams, and providing oversight to ensure quality of living for tenants.
INCA also sponsors a community program to provide networking, linkage and
employment opportunities through involvement in small enterprises such as a thrift shop
and a catering business (Conrad, 1993).

Hands on the Homeless in Columbus, Ohio, is an all-volunteer, consumer-run, non-
profit founded by a formerly homeless woman, Stacey Wright. The organization 's
mission is to support people who are homeless by going into shelters to give self-esteem
talks, help with job training and referral, and offer follow up once a family or individual
leaves the shelter. "We are their best supporters because we have been there, " states
Wright. "People tend to trust us and open up with us more than with the shelter staff. "
The organization, founded in 1997, currently has 30 volunteers and offers support only
to people who are receptive. Wright serves on a city-wide board for homeless providers
which helps her learn about new ways for Hands on the Homeless to help. "The
providers are very welcoming, " Wright adds. "Some come to us and ask us to give a
speech or talk to someone. "

The Homeless Empowerment Advisory Project (HEAP) is a program run by homeless,
or formerly homeless persons, with serious mental illness. Funded by the Massachusetts
Department of Mental Health through a $20,000 grant, HEAP has been in existence for
about six years and is affiliated with the Ruby Rogers Drop-In Center (see below). The
project operates with one paid staff person and 10 stipend positions. Members make all
decisions regarding activities and other projects of HEAP. Weekly advisory board
meetings are held for members to discuss issues related to living in the shelters. HEAP
sponsors a number of social and recreational activities for members and organized a
consumer-run smoking cessation program. HEAP also has an arrangement with the
Cambridge Adult Education Center where members can take courses at no charge.

Since 1985, the Ruby Rogers Drop-In Center in Somerville, MA, has provided a
comfortable, safe and non-threatening place where Center members can find mutual
support and advocacy for each other. Open seven days a week, the Center has
approximately 200 members — nearly half of whom are homeless — and receives between
20 and 45 people each day. The Center offers a variety of social and educational
opportunities for its members. There are currently three paid staff and 16 stipend
positions. Workers will accompany members if they need support during a court
appearance, a visit to the Social Security office or some other kind of support. The
Center will also work wi^h members to help them learn how to work while receiving
Social Security benefits. All the rules and decision-making for the Center are made by
the membership during weekly business meetings. The Center is funded through the
Massachusetts Department of Mental Health and private donations.

5-12 National Symposium on Homelessness Research

Giving Voice to Homeless People in Policy, Practice and Research

Consumer-run organizations will face considerable barriers when blazing their way onto the human
services scene. Many of these barriers are faced by all programs for homeless persons, but they may be
made even more difficult due to public skepticism about the ability of consumers to operate programs.
One of the most common difficulties is finding a location for consumer-run programs in the face of
resistance and stigma from the surrounding community. Communities do not want those "crazies" or
"bums" in their neighborhood. Unfortunately, the "not in my backyard" syndrome is still with us when it
comes to people who are homeless. But when communities find out that former clients will be running
the program as well, community resistance may grow even stronger.

In Parkersburg, West Virginia, the PS Project is faced with the fact that the local authorities do not want
to fund the program (once the three-year demonstration grants end) simply because they are consumer-
run. In Sacramento, California, the only drop-in center for homeless people was closed because of
neighborhood pressure. In Portland, Maine, it took two years for the Portland Coalition to find
handicapped accessible office space. From the perspective of the public, "it was bad enough that the
program was for people who were mentally ill, but it was run by people who were mentally ill, too,"
Director Dianne Cote has reported (Long, 1988).

While there has been a good deal of experience in siting residential programs for people who are
mentally ill in communities, there is little experience in establishing consumer-run programs against
local opposition. Although most programs build good relations with surrounding communities once they
are established, discrimination based on fear continues to be a serious challenge to the ability of
consumer-run programs to establish themselves (Long, 1988).

Other challenges consumer-run programs face include (Long, 1988):

• Severe shortage of low-cost housing coupled with supportive services. In Philadelphia, Hikmah
Gardiner, Director of the consumer-run Dew Drop-In Center, estimates there are 45,000 vacant
properties in the city and about 15,000- 20,000 homeless or near homeless people in need of
adequate and affordable housing. In Massachusetts, there are over 3,000 people awaiting housing
from the Department of Mental Health alone. This is a nation-wide phenomena. Clearly, not enough
is being done to alleviate the problem.

• A lack of a steady, adequate income for clients. Even when a client has an income, in most
communities there is little or no housing that can be afforded at the income levels provided by either
entitlements or low-paying jobs, hence they may be forced to live in shelters or on the streets.
Although food may be available through food programs, scheduled meals may be intermittent rather
than regular, and essential personal sundries cannot be bought without cash, nor can they be
purchased with food stamps.

• Difficulty in obtaining adequate and secure funding for the programs. Consumer-run programs
tend to be funded either inadequately or on a demonstration basis. Programs funded on a shoestring
budget often depend on staff members to work full-time on a one-quarter salary. Other staff
members on Supplemental Security Income work for stipends. If they took the small salary offered
for full-time work, they would have to forsake their benefits, and would be unable to pay for
housing, food, medication, health care and other necessities.

Programs funded adequately on a demonstration basis, face little prospect of being renewed by the
same funding source at the end of the period and they are left with no replacement source in sight.

National Symposium on Homelessness Research 5-13

Giving Voice to Homeless People in Policy, Practice and Research

Moreover, due to a lack of information and technical support for these newly emerging programs,
many are not adequately prepared to deal with how to access ongoing funding. Also, receipt of funds
for some of these projects is often delayed while the payment voucher snakes its way through the
bureaucracy. New programs, especially those that are consumer-run, are much less able to find ways
to carry staff members, landlords and suppliers until the funds arrive.

Gaining cooperation from traditional mental health and social service agencies. Being accepted
as colleagues by professionally-staffed organizations and agencies can be a major challenge. All
new organizations must find this acceptance, but consumer-run organizations probably face this
challenge to a greater degree than others.

Recommendations For Increasing Consumer Involvement

The recommendations below are designed to increase the level of involvement by homeless and formerly
homeless persons in policy, practice and research on homelessness. The recommendations are clustered
around the four key themes found in the literature: (1) increasing consumer involvement on decision-
making boards, (2) hiring consumers as staff, (3) funding consumer-run programs, and (4) providing
technical assistance on how to involve consumers.

Increase Consumer Involvement on Decision-Making Boards

• Require funding sources on the local, state and national level, such as HUD and the McKinney
grants, to require substantive consumer participation in the dispersion of these moneys.

• When involving consumers on boards or community meetings, there should always be more than one
consumer present. To ensure that organizations receiving McKinney funds involve consumers, the
federal government could: (1) require it as part of the application procedure, (2) make it part of the
scoring process, (3) add penalties to organizations that do not involve consumers in a meaningful
way, and (4) discuss the issue when monitoring grantees.

Hire Consumers as Staff

Broaden employment opportunities for persons who are or have been homeless at the local, state and
federal level. This is especially important for homeless people with mental illness or substance abuse
problems who have the greatest difficulty exiting homelessness and are most at-risk for becoming
homeless again.

•

Examine and modify Medicaid regulations to allow formerly homeless persons with mental illnesses
and persons recovering from substance abuse to be hired to perform Medicaid reimbursable services
(Van Tosh, 1993).

Include employment of consumers in the affirmative action statements of organizations serving
homeless persons (Van Tosh, 1993).

Offer incentives, including financial, to private non-profits serving homeless people who
successfully involve consumers in their agency. Good consumer involvement means the

5-14 National Symposium on Homelessness Research

Giving Voice to Homeless People in Policy, Practice and Research

organization employs consumers at all levels of management and solicits consumer input on policy,
programs, administration, and evaluation.

• Make it easier for formerly homeless persons with disabilities to work by gradually working their
way off SSI/SSDI benefits. Eliminate work disincentives, while ensuring that should they become ill
again, they will be able to receive benefits. This is especially important for people who have mental
illnesses, which can be cyclical (i.e., symptom-free for months or years with on-going treatment) and
life-long.

• Enable homeless people with disabilities who go back to work (and no longer receive a benefits
check), to keep Medicaid/Medicare for as long as they need it. Many disabled persons cannot go
back to work because their employer's health insurance will not cover the costs of treatment for their
chronic physical or mental disorder.

Fund Consumer-Run Programs

• Mandate that state and local agencies allocate a minimum proportion of all federal funds for
homeless housing and services to consumer-run initiatives, programs and organizations, including
money targeted for the development, research, evaluation and replication of these programs and
services.

• Mandate that county, state and federal continuation funding be assured for consumer-run
demonstration projects that are successful and meet the goals and objectives set forth by funding
agencies (Van Tosh, 1990).

Provide Technical Assistance on How to Increase Consumer Involvement

• Organize a federal task force to develop a framework for increasing consumer involvement in
federally-funded programs (Salzer, 1997).

• Create federally-funded non-governmental organizations to provide support and technical assistance
to consumer-run organizations when requested (Tyler, 1976; Van Tosh, 1993).

• Create an annual consumer involvement award to recognize consumer-run and professionally-run
organizations for outstanding achievements in the area of consumer involvement.

•

Sponsor a booklet put together by people who have experience starting consumer-run programs. The
booklet should provide a listing of groups that have been through the process and are willing to talk
to others who are just beginning. The booklet can also present problems groups can expect to run
into and how to overcome these problems

Sponsor federal public education campaigns to reduce stigma and to promote greater awareness and
understanding of homelessness. Allocate adequate funding to these campaigns so that promotional
material and events (i.e., brochures, posters, stickers, radio and television commercials, speakers
bureau) are available free of charge nationwide to interested parties wanting to promote the
campaign.

National Symposium on Homelessness Research 5-15

Giving Voice to Homeless People in Policy, Practice and Research

References

Camardese, M. B., & Youngman, D. (1996). H.O.P.E.: Education, Employment, and People Who Are
Homeless and Mentally 111. Psychiatric Rehabilitation Journal 19(4): 46-56.

Chamberlain, J. (1978). On Our Own: Patient-Controlled Alternatives to the Mental Health System.
Binghamton, NY: Haworth Press.

Chinman, M J., Lam, J. A., Davidson, L., & Rosenheck, R. Comparing the Effectiveness of Consumer
and Non-Consumer Provided Case Management Services for Homeless Persons With Serious Mental
Illness. Under review.

Cohen, M. B. (1994). Overcoming Obstacles to Forming Empowerment Groups: A Consumer Advisory
Board for Homeless Clients. Social Work 39(6): 742-749.

Conrad, E. (1993). Consumer-Run Housing in the Bronx. Innovation and Research 2(3): 53-55.

Dixon, L., Krauss, N. & Lehman, A. (1994). Consumers as Service Providers: The Promise and
Challenge. Community Mental Health Journal 30(6): 6 1 5-634.

Farrell, B. (1999). Personal Communication, June.

Federal Task Force on Homelessness and Mental Illness. (1992). Outcasts on Main Street: Report of the
Federal Task Force on Homelessness and Severe Mental Illness. Washington, DC: Interagency Council
on the Homeless.

Fisk, D., Rowe, M., Brooks, R., & Gildersleeve, D. (In press). Integrating Consumer Staff Into a
Homeless Outreach Project: Critical Issues and Strategies. Psychiatric Rehabilitation Journal.

Fowlkes, H. Personal communication, May 1999.

Friedman, D. H. Personal communication, June 1999.

Garniner, H. Personal communication, May 1999.

Gleason, M. A. Personal communication, June 1999.

Howie the Harp. (1998). The Homeless and Self-Help: A Personal View. Notes from CHAMP, 10, 12.
July.

Long, L., & Van Tosh, L. (1988). Program Descriptions of Consumer-Run Programs for Homeless
People with a Mental Illness. Rockville, MD: National Institute of Mental Health.

Mowbray, C. T., Chamberlain, P., Jennings, M., & Reed, C. (1984). Consumer-Run Alternative
Services: Demonstration and Evaluation Projects. Final Report. Lansing, MI: Michigan Department of
Mental Health.

Salzer, M.S. (1997). Consumer Empowerment in Mental Health Organizations: Concept, Benefit, and
Impediments. Administration and Policy in Mental Health 24(5): 425-434.

5-16 National Symposium on Homelessness Research

Giving Voice to Homeless People in Policy, Practice and Research

Scott, J. Personal communication, May 1999.

Smith, L. Personal communication, June 1999.

Solomon, M. L., Cook, J. A., Jonikas, J. A., & Kerouac, J. (1994). Positive Partnerships: How
Consumers and Nonconsumers Can Work Together as Service Providers. Chicago, IL: Thresholds
National Research and Training Center.

Solomon, P., Draine, J., (1995). One- Year Outcomes of a Randomized Trial of Consumer Case
Management. Evaluation and Program Planning 18(2): 117-127.

Stark, N. Personal communication, May 1999.

Tyler, R. (1976). Social Policy and Self Help Groups. Journal of Applied Behavioral Science 72(3):
444-448.

Van Tosh, L. (1988). The Benefits of Consumer- Run Homeless Programs to the Mental Health System.
Notes from CHAMP: 8-9, July.

Van Tosh, L. (1990). Final Report and Evaluation of Outreach, Advocacy and Training Services for the
Mentally III Homeless (Project OATS). Philadelphia, PA: Project SHARE.

Van Tosh, L. (1994). Consumer/Survivor Involvement in Supportive Housing and Mental Health
Services. The Housing Center Bulletin 3(1): 1-6.

Van Tosh, L., Finkle, M., Hartman, B., Lewis, C, Plumlee, L.A., & Susko, M.A. (1993). Working for a
Change: Employment of Consumers/Survivors in the Design and Provision of Services for Persons Who
Are Homeless and Mentally Disabled. Rockville, MD: Center for Mental Health Services.

Wilson, S. F., Mahler, J., & Tanzman, B. (1990). Consumer and Expatient Roles in Supported Housing
Services. Burlington, VT: Center for Community Change Through Housing and Support.

Wright, S. Personal communication, June 1999.

National Symposium on Homelessness Research 5-17

To Dance With Grace:
Outreach & Engagement To Persons On The Street

Sally Erickson, M.S.W.

Jaimie Page, M.S.W., L.S.W.

Abstract

Outreach and engagement strategies are critical in helping homeless persons transition from the streets
into housing and services. A literature review was conducted and commonalities across populations were
found (although the preponderance of literature describes homeless persons with mental illnesses).
Definitions, exemplary practice models, values/principles, worker stances, measurable outcomes, and
multi-level factors relating to outreach and engagement are presented as well as issues related to research
and funding.

Lessons for Practitioners, Policy Makers, and Researchers

Outreach work is based on a foundation of strong values, principles and unique worker stances

Engagement is the key in Outreach

The homeless persons outreach is designed for are those who unserved or underserved by existing

agencies and who aren't able or willing to seek services from those agencies

The goals of outreach are to develop trust, care for immediate needs, provide linkages to services and

resources, and to help people get connected to mainstream services and ultimately into the

community through a series of phased strategies

Effective outreach has been demonstrated, with positive outcomes

Peer based outreach and the use of the expertise of homeless and formerly homeless persons and

consumers are valued and should be actively sought out

Discrimination and marginalization are part of the experience of both outreach clients and workers;

as a result, advocacy must take place at all levels

Outreach services cannot exist in isolation from larger systems: both homeless systems and

mainstream systems at community, state, and federal levels

Outreach services must be included, required, valued, and funded as part of a national and local

continuum of care

More research, including controlled and longitudinal studies, are needed particularly in answering

the question of what factors promote success in helping people access mainstream services and

resources across homeless outreach populations

National Symposium on Homelessness Research 6-1

To Dance With Grace: Outreach & Engagement To Persons On The Street

The process of outreach and engagement is an art, best described as a dance. Outreach workers take one
step toward a potential client, not knowing what their response will be — will the client join in or walk
away? Do they like to lead or follow? Every outreach worker has a different style and is better at some
steps than others. To dance with grace, when the stakes are high, is the challenge for all of us.

In the U.S., we now have the benefit of more than ten years of Mc Kinney funding which has made
possible scores of outreach programs across the country. Rural and urban, small and large,
comprehensive or finite, they reach out to people who are homeless and challenged by poverty, violence,
marginalization, poor health, mental illness, substance abuse, and other issues.

This paper will provide definitions; exemplary practice models, including worker stances,
values/principles, outreach functions and services, outreach across populations; measurable outcomes;
and an extensive bibliography for further inquiry. The preponderance of available literature was
published in the late 1980s and early 1990s, and focuses on mental health-related outreach programs.
The few outreach-related articles published in recent years perhaps reflect the greater use, acceptance,
and integration of existing outreach programs as part of a community's effort to provide a "continuum of
care" to persons in need. This paper will present both a review of the literature and experiential
information relating to best practices.

Priority Home! (1994) describes the federal plan to break the cycle of homelessness by "public and
private mental health, medical, and substance abuse service-providers to initiate street outreach efforts,
the utilization of safe havens ... and implementation of a continuum of care..." This federal validation of
outreach as an accepted and expected part of a community solution to homelessness, which includes
access to housing and services, recognizes the unique efforts of outreach workers across the country.

Definitions

Outreach is the initial and most critical step in connecting, or reconnecting a homeless individual to
needed health, mental health, recovery, social welfare, and housing services. Outreach is primarily
directed toward finding homeless people who might not use services due to lack of awareness or active
avoidance (ICH, 1991; McMurray-Avila, 1997), and who would otherwise be ignored or underserved
(Morse, 1987). Outreach is viewed as a process rather than an outcome, with a focus on establishing
rapport and a goal of eventually engaging people in the services they need and will accept (ICH, 1991;
McMurray-Avila, 1997). Outreach is first and foremost a process of relationship-building (Rosnow,
1988) and that is where the dance begins.

Engagement is a crucial process for successful outreach. It is described as the process by which a
trusting relationship between worker and client is established. This provides a context for assessing
needs, defining service goals and agreeing on a plan for delivering these services (Barrow, 1988, 1991;
ICH, 1991; Winarski, 1994). Some clients require slower and more cautious service approaches (Morse,
1987). The engagement period can be lengthy-and the time from initial contact to engagement can range
from a few hours to two years (ICH, 1991) or longer. Effective workers can "establish a personal
connection that provides a spark for the journey back to a vital and dignified life" (Winarski, 1998).

6-2 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

Assumptions Of Exemplary Programs

Based on a review of the literature and best practices found in the field, the following are important
elements to address in a good outreach program: characteristics of the population served, values and
principles, worker stances/characteristics, and goals of outreach.

Programs cannot assume is that all communities have the same percentages of "types" of homeless
people. There is a range in the population that may differ from one region to the next. Rather than
basing interventions on formulaic assumptions such as "1/3 mentally ill, 1/3 veterans, 1/4 families," each
community needs to assess the characteristics of it's homeless persons, identify service gaps, and develop
effective responses. For example, in one city 80 percent of the homeless were single men, while in
another, 65 percent were families with children (U.S. News & World Report, 1988).

Characteristics Of Homeless Persons Needing Outreach

Outreach programs attempt to engage individuals who are unserved or underserved by existing agencies
(Axelroad, 1987). This distinction is significant because the outreach model was developed to meet the
large service gap found among this unique population. An outreach model is unnecessary and even
counter-productive with other populations.

Outreach programs serve persons who may have psychiatric disorders and/or substance abuse issues.
They may be highly vulnerable and considered "difficult to serve" (Rog, D.J., 1988). They usually
cannot negotiate the requirements of or trust traditional service-providers. These persons may have poor
health, lack insurance, and are unable to make or keep medical appointments and follow through with
complex medical regimes. Homeless youth may be those who are estranged from family and fearful of
adult service-providers. Homeless youth are perhaps the most vulnerable group of youths, and are in
need of creative and early interventions, in order to prevent an acclimation to street life which includes
prostitution, substance abuse, and crime. Further, homeless teems with children are viewed as perhaps
the most vulnerable of homeless families (Bronstein, 1996).

Two factors commonly associated with homelessness among women include pregnancy and the recent
birth of a baby. Homeless pregnant women experience a range of problems including poverty, isolation,
substance abuse, and histories or past and present victimization. A lack of prenatal care and poor
nutrition may also exacerbate health problems (Weinreb, et al., 1995).

Other groups include the elderly, women escaping domestic violence, families, and marginalized persons
such as those who are transgendered and those in the sex industry.

Many of the people outreach programs attempt to serve are isolated, have minimal resources, minimal
access to social services (Sullivan-Mintz, 1995; ICH, 1991), have had negative experiences with service-
providers (McMurray-Avila, 1997), and have been victims of violence (Goodman, et al., 1995; Weinreb,
et al., 1995). Workers give priority to those who are most at-risk who are least likely to seek out and
successfully access available services, for whatever reason: fear, mental status, lack of insight and
motivation, or low self-esteem. Rog (1988) describes the need to reduce barriers to service-utilization
and facilitate the engagement process. Workers may also encounter persons who are able to access
services and can help by providing one-time information and direction, but the focus is on the former
group.

National Symposium on Homelessness Research 6-3

To Dance With Grace: Outreach & Engagement To Persons On The Street

Values & Principles Of Outreach

Successful outreach programs must be based on a core set of values and principles which drive
interventions. Values and principles also serve to set the stage for developing realistic goals in an arena
of limited resources and potentially slow progress.

• A person orientation: Exemplary programs possess a philosophy which aims to restore the dignity of
homeless persons, dealing with clients as people (Axelroad, 1987; Wobido, 1990).

• Recognizing clients' strengths, uniqueness, and survival skills.

• Empowerment & self-determination: (Sullivan-Mintz, 1995) Workers can facilitate this by presenting
options and potential consequences, rather than solutions (Rosnow, 1988), by listening to homeless
persons rather than "doing" for them, and by ensuring a balance of power between homeless
individuals and outreach workers (Rosnow, 1988).

• Respect for the recovery process (Winarski, 1994): Behavior change is on a continuum. Small
successes are recognized. Any move toward safer/healthier activities is viewed as a success. Clients
need to recognize for themselves how change may be beneficial, in relation to their own goals.

• Client-driven goals (Winarski, 1994): Services and strategies are tailored to meet the individuals'
unique needs and characteristics (Morse, 1987). Workers start with clients' perceived needs and go
from there.

• Respect (Cohen and Marcos, 1992): Workers are respectful of people, including their territory and
culture. Outreach workers view themselves as a guest and make sure they are invited, welcome, or at
least tolerated. Workers must take care not to interrupt the lifestyle of the people they are trying to
help. Lopez (1996) makes the point that clients don't lose the right to be left alone in the privacy of
their home even when that client calls the streets home. Clients are viewed as the experts in their life
and on the streets. The worker takes the role of consultant into that lifestyle.

• Hope: Workers instill a sense of hope for clients while helping them maintain positive, realistic
expectations. Unrealistic expectations may bring on clients' cycles of frustration, despair, and
hopelessness, as well as anger at the outreach worker. The worker restores hope in clients who have
faced years of disappointment as well as reframes raised expectations. The worker needs to
communicate to the client that changes may take considerable time, effort, and patience (Morse,
1991).

• Kindness: People are always treated with warmth, empathy and positive regard, regardless of their
behavior or presentation.

• Advocacy: Workers advocate for social justice on many levels.

Outreach Worker Stances/Characteristics

There are common worker stances/characteristics found among successful outreach workers and
programs. These characteristics are critical because successful engagement will largely be determined by
the relationship between clients and workers. Effective worker stances/characteristics include:

• Good judgment, intuition and street sense: this includes safety for themselves and the client-being
observant and vigilant, as well as using good common sense. Strategies include going out with a
partner, avoiding closed, remote or dangerous areas, developing a relationship with local police
(Winarski, 1998), carrying a cellular phone, dressing appropriately, and assessing situations before
acting.

• Non-judgmental attitude (ICH, 1991): Regardless of the worker's personal beliefs, no behavior on the
part of the client is morally judged.

6-4 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

• Team player: Workers must know when to ask for help, from getting backup on the streets to a
second opinion in clinical assessments. Outreach staff must have a strong commitment to the "team"
approach to service delivery (Axelroad, 1987; Wobido, 1990).

• Flexibility (Rosnow, 1988JCH, 1991): Outreach workers are flexible in reassessing daily work
priorities, in setting work schedules, and in the treatment planning process (Morse, 1987), and
content.

• Realistic expectations: Workers have an "expectation of non-results." They understand that they will
not be able to "cure" or "save" clients (Axelroad, 1987; ICH, 1991), and at the same time continue to
persevere.

• Commitment: Outreach workers are both consistent and persistent in their dealings with clients
(Axelroad, 1987; Wobido, 1990). They do what they say they are going to do and only make
promises they can keep (Sullivan-Mintz, 1995). They are in it "for the long haul" and continue to
persevere.

• Less is more. At the outset of intervention, there is less application of intensive and costly treatment,
less professional distancing, less rigidity, less intrusiveness, and less directiveness (Rosnow, 1988).
Services offered are purely voluntary (Cohen, 1989).

• Altruism: Staff find rewards in doing outreach work, such as a spiritual commitment to helping
others, furthering an academic interest, or simply enjoying the process of working with individuals
(Axelroad, 1987).

• Sense of humor: the ability to use humor at appropriate times, as well as maintaining as sense of
humor during difficult times is essential.

• Creativity & resourcefulness are strengths that outreach workers tap into daily.

• Cultural competency: Workers demonstrate competence across ethnicity, gender, transgender,
lifestyle, and age spectrums.

• Resilience: Workers are resilient and patient in a work environment marked by high turnover,
difficulty tracking clients (McQuistion, et al., 1996), high stress, lack of resources, and lack of
immediate improvement in the clients they serve. Effective workers are able to continue working
despite the difficulties endured by their clients, without personalizing them.

Outreach programs vary in relation to considering credentials, ethnicity, or gender when hiring outreach
workers. People with a variety of backgrounds may function as mental health outreach workers:
physicians, social workers, nurses, nurse-practitioners, and para-professionals. Some programs employ
formerly homeless persons with mental illnesses (Axelroad, 1987; Morse, 1987). A survey of ACCESS
programs reported that 75 percent of programs do not require a bachelor's degree for an outreach worker.
More important were characteristics such as a personal commitment to the work, flexibility, and a
willingness to adjust schedules to the needs of the clients (Wasmer, 1998).

Some programs state that it is not necessary to have workers of the same ethnicity, cultural background
or gender as the clients, nor who have a lot of street experience. They further state that the only essential
characteristic is a common language (Axelroad, 1987; Nasper, 1992). However, an outreach team of two
males in Milwaukee found that they had served 80-90 percent men and had difficulty establishing trust
with homeless women. As a result, they now have mixed gender teams (Rosnow, 1988). Agencies
promote an equal opportunity atmosphere, and the staff composition mirrors that of the general
population.

Many outreach programs successfully use mental health consumers as outreach workers (Tosh, 1990 and
1993, and Lieberman, et al., 1991) and/or formerly homeless persons (Mullins, 1994). The benefits of
such peer models allow for effective outreach, sharing of their personal expertise, fostering of
partnerships between consumers and non-consumers, increased self-esteem of the working peers, and the

National Symposium on Homelessness Research 6-5

To Dance With Grace: Outreach & Engagement To Persons On The Street

evolution of consumers becoming active in changing services throughout the country.
Consumers/peers/formerly homeless persons can contribute significantly in the development of
program design, implementation, and evaluation. Their expertise should be actively sought out by
outreach programs. To be sure, homeless persons and formerly homeless persons have expertise,
skills, and insight that professionals who have never experienced homelessness lack. Programs
recognize that peers working in homeless and mental health fields often endure the pressures of
maintaining their own housing and overcoming stigma (Tosh, 1993), allow for reasonable
accommodations to assist them, and offer training and on-going meetings (Leiberman, et al., 1991).

Goals of Outreach

There are four main goals of outreach found across different areas of outreach client populations. The
first is to care for immediate needs (Plescia, 1997), including to ensure safety, provide crisis intervention,
refer to immediate medical care, and help clients with immediate clothes, food, and shelter needs.
Workers must develop a trusting relationship (Plescia, 1997; Cohen and Marcos, 1992; Sullivan-Mintz,
1995) in order to achieve the additional goals of providing services and resources, whenever and for as
long as needed (Winarski, 1998). Lastly, workers aid in connecting clients to mainstream services
(Plescia, 1997).

An inherent factor related to these goals is the notion of phasing. Objectives are developed and reached
over a period of time with small steps that are directed to a more structured, service-oriented goal.
Persons often phase from accepting food from the outreach worker, to developing trust, to discussing a
goal that in part can be achieved through services provided in the community and to accepting those
services. Case management goals are gradually developed by both the client and worker. Outreach and
engagement principles carry over into case management and are viewed as an ongoing process. As trust
develops, clients take a more active role in setting and achieving case management goals. Ultimately, the
goal is to successfully phase or integrate persons into the community and/or into a social service agency
(ies) which would assume the task of promoting community integration. Just as clients are phased into
outreach services from the streets, they are phased into the community from outreach.

Outreach Service Structure

There are at least three ways of classifying outreach models found in the literature. One set looks at a
linkage model versus a continuous relationship model. A second set looks at a mobile versus fixed
model. A third set describes models based on a service continuum.

Linkage vs. Continuous Relationship Model

Some outreach programs serve as linkages, referring clients to mainstream mental health or other service-
providers. Examples of "find and link" programs are New York's Project HELP, which conducts in-vivo
assessments and delivers people to the psychiatric hospital by voluntary and involuntary means, and
Chicago's Mobile Assessment Unit (MAU), that visits shelters and streets to identify mentally ill persons
and link them to resources (Wasmer, 1998). Other examples may include linking temporarily displaced
families with housing.

Linkage-only programs that do not provide follow-up tracking have been determined to be ineffective for
some disabled populations. A 1986-87 study of 13 federally funded homeless mental health
demonstration programs reported that most outreach programs were running ineffective models. Many
spent the majority of their time in screening and identifying individuals and providing verbal referrals,

6-6 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

but little follow-up assistance. One project contacted 430 eligible persons, yet only 22 received follow-
up mental health treatment. Five found housing and three received entitlements (Hopper, et al., 1990 in
Morse, 1996).

Providing linkage-only services to certain homeless populations can lead to barriers and service gaps,
resulting in lost clients. Morse (1991, 1996) suggests strategies to increase the effectiveness of this
model: incorporate the expectation of an eventual service-provider transition early in the engagement and
service-planning with a client; remain involved and actively involve the client in the referral process,
including scheduling appointments, arranging transportation, and providing emotional support; work with
the linkage site staff, informing them about client needs and characteristics; provide follow-up support as
needed to both client and new staff; and provide advocacy on behalf of the client if needed.

In a continuous relationship model, workers perform outreach and continue on as the person's case
manager. Outreach has been shown to be a necessary component of ongoing case management for
mentally ill clients. Axelroad and Toff (1987), point out the difficulty in distinguishing outreach from
case management for homeless mentally ill persons for two reasons. First, the fragility of the population
requires trust and continuity of care when helping clients move from an outreach phase to a treatment
phase. Second, outreach workers must often provide case management services because of the frequent
shortage of appropriate and relevant case management services for which to refer clients.

The drawbacks to the continuous relationship model are small recommended caseloads, 10:1, which may
be unrealistic for many agencies, and little capacity to outreach with new clients (Morse, 1991, 1996).
However, the approach has been shown to be effective at maintaining contact with clients and housing
retention (Morse, 1996). In addition, outreach workers may prefer the excitement, lack of structure, and
immediacy of outreach. For this and other reasons related to individual personality traits, some outreach
workers may not be as effective as case managers.

At Safe Haven in Honolulu, outreach workers opted for the continuous relationship model out of
necessity when they were unable to transition "graduated" residents to case managers at the community
mental health centers. Historically, the engagement strategies used in interaction between clients and
outreach workers have been substantially different from strategies used at traditional service settings,
leaving clients with little incentive to transition to a less user-friendly service-provider. Outreach roles
expanded to encompass case management and advocacy, and they remained connected with clients
through follow-up. Perhaps as a result, a majority of Safe Haven clients have successfully transitioned
into the community. In Safe Haven's first 28 months, 43 residents transitioned from the program — 63
percent into permanent independent housing, with 98 percent of these retaining their housing.

Mobile vs. Fixed

Outreach may be mobile or fixed depending on the needs of the target population (Sullivan-Mintz, 1995).
Outreach may take place on the streets, as well as in shelters, drop-in centers, emergency rooms,
hospitals, and jails (Axelroad, 1987; Morse, 1987). The mobile model requires that the projects be
"equipment heavy," including agency vehicles/vans, employee cars, and communication systems such as
pagers, cellular phones, and walkie-talkies (Wasmer, 1998).

Fixed-site outreach programs such as drop-in centers or day programs for the mentally ill, within high-
density homeless areas, can be more easily accessed by greater numbers of clients, increase staff
efficiency, and can provide additional incentive services. Many outreach programs have both a mobile

National Symposium on Homelessness Research 6-7

To Dance With Grace: Outreach & Engagement To Persons On The Street

and fixed-site component (Morse, 1987). In a survey of eight ACCESS programs, 77 percent of clients
were engaged by mobile methods and the balance at drop-in centers. (Wasmer, 1998)

For certain clients with primary substance abuse issues, mobile outreach is more successful for several
reasons. There is less stigma and community opposition when outreach workers meet clients individually
on the streets rather than having clients come to a centralized location. Another reason is that clients
who are high or intoxicated are often asked to leave fixed service sites.

Outreach Continuum

Wasmer (1998) describes a link/serve continuum, with outreach programs that "find and link" or "find
and serve." The latter include case management programs, assertive community treatment and intensive
case management programs, drop-in centers, shelter-based programs, and low demand residences/safe
havens. Of eight ACCESS outreach programs Wasmer surveyed, all were the "find and serve" type.

The Team Approach

Different types of team approaches are described in the literature, depending on the mission of the team.
They may focus on emergency psychiatric intervention, case management, health care, HIV
education/prevention, harm reduction for sex industry workers, substance users, and others.

With mentally ill persons, using a team approach after engagement has been established assures that a
client will learn to develop trusting relationships with several staff people. It also increases the
likelihood of being able to attain assistance when necessary. Teams can include or have access to social
workers, nurses, nurse-practitioners, substance abuse staff, medical and psychiatric consultants, and other
outreach specialists. The team approach can also aid in combating burn-out and expanding caseloads
(Axelroad & Toff, 1987) and the inherent sense of isolation individual outreach workers can feel. A
study of five New York outreach programs showed that 98 percent of homeless mentally ill clients had a
significant relationship with more than one staff member, indicating that involvement with the programs
did not consist only of the client's relationship with a single worker (Barrow, 1988).

One survey of eight ACCESS-funded outreach programs reported that all sites used a team approach,
with majority of first contacts made by two mental health professionals, one taking the lead and one
observing (Wasmer, 1998).

Exemplary Outreach Functions/Services

Based on a review of the literature (Winarski, 1994, 1998; ICH 1991; Morse, 1996) and review of best
practices in the field, several outreach functions/services are common among exemplary outreach
programs.

Determine the Target Population

Outreach programs cannot serve all potential clients. Exemplary programs have clearly defined program
goals and objectives. Some programs target a subset of the population, such as persons with mental
illnesses, and others limit outreach to a particular geographic or "catchment" area (ICH, 1991).

If geographic limits or catchment areas are a defining factor in determining the target population, then the
size of the area allows for repetitive contact. Knowing fewer clients better is the goal. Workers have the

6-8 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

flexibility to leave this zone and follow their potential clients elsewhere (McQuistion, 1996). If a client
is determined to be out of the mission of the outreach program, provisions can be made for referring non-
target clients to the appropriate programs. (ICH, 1991).

Locate Street Dwellers

Once workers identify the target population, the next task is to locate them. Individuals can be found
under bridges and freeway overpasses, alleys, parks, and vacant lots. In rural areas or on the fringes of
urban areas, outreach workers may go to the beaches, riverbanks, foothills, wooded areas or desert. They
may be in public facilities such as libraries, airports, and bus stations. They may be in places where
people live on the edge of homelessness, such as welfare hotels, cheap motels, and SROs. Some teams
have special arrangements with jails, detox/treatment programs or other institutions, to enter and make
contact with ongoing clients or potential clients regarding available services on their release (McMurray-
Avila, 1997).

Sometimes homeless persons will serve as voluntary scouts for outreach workers, alerting them to
homeless persons who appear to be in need of intervention. Volunteer homeless persons can also help
outreach workers locate clients who have been missing for some time. Outreach coalitions, comprised of
outreach workers from different agencies, can meet periodically and help each other locate missing
clients, as well as help each other stay on top of recent trends in geographic concentrations of homeless
persons.

Outreach conducted by peers, such as youth, substance users, or sex industry workers, can be effective in
locating, engaging, and completing assessments of the clients perceived needs. When going out in teams
with non-peer professionals, they are able to introduce professionals to participants on the streets. Youth
who serve as peers/mentors for other homeless youth, for example, help convey a sense of
understanding of the factors that may have led them to becomes homeless such as abuse and share
resource information, teach safety, and help make a bridge between street life and the world of
"professional" adults whom they generally don't initially trust. Hiring program participants
encourages increased feelings of self-esteem and empowerment on the part of participants and generates
empathetic, effective outreach staff (Mullins, nd). An effective outreach program for at-risk HIV
youth in the sex industry in New York provides training to peer youth outreach workers, a support
group, an active and real voice in program development, and a stipend for their work. These
youth outreach workers have been successful in saving lives and reducing risk associated with their
lifestyle and that of their peers in a way that adults could not have.

Engagement

Engagement is a crucial, on-going, long-term process necessary for successful outreach (Morse, 1991,
1997). In a study of five New York outreach programs, homeless mentally ill clients first contacted by
outreach workers were engaged an average of 3.9 months before intensive services began (Barrow,
1988).

Engagement reduces fear, builds trust, and sets the stage for "the real work" to begin (Cohen, 1987).
Morse (1991) classifies engagement in terms of four "stages": 1) setting the stage, 2) initial engagement
tactics, 3) ongoing engagement tactics, and 4) proceeding with the outreach/maintaining the relationship.

Setting the stage: Workers become a familiar face and begin to establish credibility in places where
homeless persons frequent (Morse, 1991). They use a non-threatening stance/approach (Cohen and

National Symposium on Homelessness Research 6-9

To Dance With Grace: Outreach & Engagement To Persons On The Street

Marcos, 1992), and get some kind of permission from the client, either verbal or non-verbal, before
approaching. In these early stages, workers gently cease interactions that appear too overwhelming to
clients and try again later.

Initial engagement tactics: Workers attempt to engage the potential client in conversation, beginning with
non-threatening small talk (Morse, 1991). This allows workers to assess for signs of problems and also
the impact of the interaction. Is the client feeling intruded upon (Morse, 1991)? Workers provide
incentive items (Cohen, 1989; Cohen and Marcos, 1992) such as food, drinks, condoms, cigarettes,
vitamins, toiletries, etc., with real and perceived benefits that promote trust.

Ongoing engagement tactics: Workers begin to "hang out" and "share space" with clients (Morse, 1987).
As clients become more comfortable, workers begin to provide or help the client to meet some important
needs that can be easily solved or obtained. This might include providing transportation to get clothes,
linking the client with medical care, and providing incentive services that are based on clients' perceived
needs (Cohen, 1989). Engagement strategies used in the initial phase continue.

Proceeding with outreach/maintaining the relationship: As trust is established, workers help clients
define service goals and activities, which may include the pursuit of housing, income, and medication
(Morse, 1991). Staff accompany clients to appointments, help them prepare for upcoming tasks, and
assist in the negotiation of service settings.

At Honolulu's Health Care for the Homeless Project, staff use six simple engagement strategies in their
interactions with diverse groups.

• Treating people with positive regard, by demonstrating that workers are glad to see them and care
about them. Workers remember details of past encounters and discussions. Workers are honest,
humble, and share information about themselves when appropriate, to equalize power and respect.

• Working with their perceived needs

• Providing incentive items and services, as listed above.

• Letting clients set the pace whenever possible

• Communicating effectively, both verbally and non-verbally. For example, workers get to the client's
level. If the client is sitting on the curb, the worker sits on the curb. Workers gauge the expression
of language so that it fits with that of the client's in terms of vocabulary, speed, eye contact, and
culturally relevant responses.

• Being creative. For example, an outreach dog is used by one worker. A pet is a great ice-breaker
and has been effective in connecting with some paranoid and very isolated mentally ill persons. One
woman who would previously never speak to workers, will now talk to the dog (but still not to the
worker), providing opportunities for ongoing assessments, and topics for future discussions. Staff
use art as an engagement tool, and incorporate client interests, like hobbies, books, and collections, in
incentive items and discussions. When possible, outreach workers transfer engagement strategies on
the streets to the clinics, where clients can receive further care. For example, a drawing by a client
on the streets might be displayed in the clinic where pertinent services are offered. Other effective
programs use creativity as an outreach foundation and reach out and engage homeless persons
through such non-traditional approaches as the use of theater, the arts, and creative grass-
roots community organizing.

6-10 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

Assessment

Workers need to conduct an assessment of an individual's comprehensive, holistic needs before providing
services and linkages to meet these needs (Morse, 1987). The assessment process is informal and usually
takes place over time. Outreach workers, rather than asking direct questions, may make inferences
(Cohen and Marcos, 1992) about an individuals' mental and physical state. As the relationship builds,
workers may be able to ask more direct questions as they try to get more history.

The crises faced by many homeless persons are usually related to basic survival, such as lack of food and
water, lack of clothing, exposure, poor health, and deteriorated mental status. Outreach workers must
initially provide basic triage assessment to help identify and respond to potential life-threatening
problems.

When clients are experiencing potentially life-threatening problems such as dangerousness to self or
others, serious medical problems, or exposure to extreme cold or heat, outreach workers must be
prepared to intervene. Whenever possible, workers should encourage clients to voluntarily accept
treatment, and present this treatment within the context of the client's perceived needs. When the
situation is life-threatening, workers should be prepared to initiate involuntary treatment or interventions
that will reduce harm. Clinical supervision in this situation is highly recommended so as to not infringe
upon clients' rights and self-determination.

Provide Basic Support

In response to a lack of homeless persons being able to get their basic needs met, workers help them to
access food, clothing, shelter (Axelroad, 1987), showers, laundry, and basic medical care. In some
cases, homeless persons may not perceive these as basic needs, particularly in the case of those with
severe mental illness who have decompensated and/or those with chronic substance use problems.
They may perceive other needs as more important. In these cases, workers can educate people
about the resources available when they're ready for them, encourage them to use them when
needed, accompany them to the service sites, and suggest what may be a marriage of the worker's
perception of what the homeless person may need, and what the person him/herself feels they need.

Linkage

Outreach programs should attempt to engage individuals who are unserved or underserved by existing
agencies, and link them to resources. Many persons who are homeless are unaware of what is available
(McMurray-Avila, 1997). Effective workers learn about available resources and establish working
relationships with the people who provide these resources. Workers also tap into the knowledge of other
homeless persons, who are often more aware of details and subtleties of changing resources. Effective
workers are able to make durable linkages across systems: homeless/non-homeless systems, youth
to adult systems, and across private and public systems. When these systems aren't user friendly
to homeless persons, workers advocate for change.

Advocacy

Clients who are disenfranchised and discriminated against, often need outreach workers to assume an
advocacy role on their behalf. This occurs on many levels such as when helping clients access
benefits and services to which they are entitled, within the outreach worker's own agency, and
within the criminal justice system. Indeed, in many communities, political views about

National Symposium on Homelessness Research 6-1 1

To Dance With Grace: Outreach & Engagement To Persons On The Street

homelessness are resulting in what may be perceived as meaner streets where persons are
criminalized because of their homelessness. This can be seen in arrests for trespassing, criminal
littering, and loitering. Legislation is increasingly pursued as a vehicle to continue criminalization
of homeless persons, the effects of which are devestating to the homeless person and
counterproductive to the outreach process.

Follow-up

Effective workers provide short-term follow up with respect to immediate tasks at hand and long-term
follow-up with clients to ensure that they remain in a stable situation.

Outreach Across Populations

Primary health, mental health, and substance abuse treatment approaches similarities in outreach
approaches are found in different treatment areas and client populations including families, veterans,
mentally ill and transgendered persons, sex industry workers, substance users, HrV+ persons, and youth.

Health

A significant characteristic of homeless persons is poor health. A one-year study of 300 mentally ill
homeless persons in New York City, revealed that 73 percent suffered from at least one medical
condition in addition to a psychiatric diagnosis. The most common medical conditions were peripheral
vascular diseases, anemia, infestations, and respiratory diseases, particularly tuberculosis. 35 percent had
a secondary diagnosis of substance abuse (Marcos, 1988).

A two-year study of 1,751 homeless clients in Honolulu showed exceptionally high rates of mortality,
with an average life expectancy of 48 years. Death rates have long been used as a measure of deprivation
and as a guideline for public health resource allocation. With that in mind, homeless populations are in
urgent need of increased attention and health care spending (Martell, 1992). A Philadelphia study of
mortality rates for homeless people was 3.5 times that of the general population (Hibbs, 1994). Another
study showed that causes of death varied by age group: (1) homicide: men ages 18-24; (2) HIV/AIDS:
persons 25-44; and (3) heart disease and cancer: persons 45-64 (Hwang, 1997). In a study of
hospitalizations of homeless persons, admissions to acute care hospitals were five times greater than the
general population. They were admitted nearly one hundred times more often to the state psychiatric
hospital (Martell, 1992).

Health care delivery to homeless persons can be challenging due to: lack of insurance, distrust of service-
providers, bad experiences with health care in the past, difficulty making and keeping appointments,
difficulty with complex medical and follow up care routines, and lack of understanding or interest in
health problems in relation to seemingly more important issues at hand.

As with mental health and substance abuse, health care approaches for homeless persons are based on a
process of engagement, assessment, planning, advocacy, education/motivation, and follow up. There are
different models of health care approaches to serving persons who are homeless. Health care services
may be provided at either permanent or mobile clinics and at rotating sites, some of which may be near
homeless shelters. Health care providers may include salaried or voluntary physicians, physician
assistants, nurses, and/or nurse practitioners who comprise a medical team. They reach out to homeless
persons at sites where they have agreements with the host agencies. The goal is to provide care and help

6-12 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

clients access a more mainstream medical system that will continue to be available to them. Staff make
referrals and arrange transportation and an escort if needed (Plescia, et al 1997).

Escorting clients to appointments can be critical if a person is unable to go on his/her own. Staff can
help clients by making medical appointments, preparing them for the appointment (getting insurance
card/paperwork in order, educating them about what might be expected), advocating for them if needed,
translating medical jargon, and helping them follow through with aftercare instructions and
appointments. Further, outreach workers can be the "eyes" and "ears" on the streets for health care
providers who are monitoring clients from afar. When clients reach a dangerous state of health, outreach
workers can elicit assistance from mobile medical outreach staff, or stationary medical staff who are
willing to leave a clinic and provide in-vivo services.

Often, homeless persons are more willing to address health problems because of decreased stigma,
compared to willingness to address mental health or substance abuse issues. As outreach workers
continue to engage clients during the health care process, they can begin to slowly and gently address
other issues. For example, they may work toward obtaining clinical history and the client's thoughts and
perspectives regarding their experiences with mental illness, substance abuse, and other areas.

Outreach workers play a key role in illness prevention, from providing blankets and socks, helping clients
access insurance and free medication/medical care, and educating them about topics like safe sex,
hepatitis, TB, harm reduction, and nutrition. They can help clients get food and vitamins, and help them
obtain past medical records and reconnect with previous service providers who may be familiar with their
medical case(s). Outreach workers can also help by being aware of other organizations' involvement in
medical care so that there can be nd ears" for psychiatrists and clinicians making decisions about the
direction of mental health care.

Effective outreach workers are able to demonstrate flexibility in their treatment responses. For example,
with some clients, the connection can be so tenuous that the engagement phase can take months or even
years of gentle, slow, and careful interactions. Other clients' mental status may indicate the need to set
limits. For clients who lack insight into their mental illness, workers take an education and normalizing
approach, emphasizing the stressful nature of homelessness (Morse, 1991). Workers can help clients
make connections between homelessness and their perception of the bad things that happen to them,
hoping to spark some motivation to consider housing and other related social services. Workers can also
help clients make connections between negative symptoms and the potential relief that medications or
other interventions might offer. However, discussion about medication can only occur after sufficient
trust has been established. For many people, the only mental health involvement they recall has been
involuntary and coercive, usually resulting in unwanted medication and treatment.

Some clients may persist in denying the existence of a mental illness, but become successful in housing
(Barrow, 1991). Workers can help clients translate street skills into independent living skills while
treatment and referrals progress. Engagement strategies can help with linkage to services. For example,
one client on the streets liked jewelry, and a lot of it. The outreach worker invited her to the clinic where
health and mental health services are provided, stating that they had "a lot of jewelry there." The
outreach worker alerted staff, who the next day brought in jewelry from home and from thrift stores. The
client enjoyed picking out one piece of jewelry every time she came to the clinic. This allowed linkage
to services in a clinic where she learned to trust service-providers. Similar creative linkages are required
to ensure success.

National Symposium on Homelessness Research 6-13

To Dance With Grace: Outreach & Engagement To Persons On The Street

Outreach workers can help prepare clients as they begin to access services, at the same time informing
staff at those agencies about the client's unique needs, strengths, and interests to help ensure successful
transition.

Substance Abuse

Outreach to substance users crosses many sub-groups, such as those with dual diagnoses, sex industry
workers, and persons with HIV/AIDS. One major gap in services to persons with substance abuse
problems is the lack of an entry point into services for those who don't want formal treatment (Bonham,
et al., 1990). A sub-group of this population are the "public inebriates" (Willenberg, et al., 1990). Three
errors in treatment modalities have contributed to failures with this population. One is that the
population is severely and chronically disabled. Second, programs often have unrealistic and high goals.
Third, treatment models used are those that are more successful with middle-class, non-alienated
alcoholics (Willenberg, et al., 1990). Moreover, treatment programs often fail to take into consideration
cultural factors and fail to address the serious marginalization of disenfranchised groups. Engagement
strategies are much the same as with health or mental health outreach — a non-judgmental stance,
listening, educating, and linking. Project Connect's service model is based on principles that services fit
client needs, focus on their strength rather than weaknesses, and that the worker/client relationship is
primary and essential (Bonham, et al., 1990). Worker activities can include education about safe sex and
safer drug use and newsletters, and connecting clients to support groups and sobering up stations
(Bonham, et al. 1990). Incentive items may include vitamins, condoms, bleach kits, and clean needles.
Alcoholics and drug users who are homeless frequently lack the motivation or skill to seek out currently
available services. They often distrust service-providers because of real or imagined poor treatment in
the past, or difficulty negotiating the system (McCarty, et al., 1990).

Since many street users do not have insight into the harmfulness of their drug use, outreach workers may
implement the use of a "Motivational Interviewing" (Miller and Rollnick, 1991) or "Stages of Change"
(Prochaska, et al., 1994) approach. Programs may want to consider training in these models for all staff,
rather than having one designated substance abuse counselor. Homeless persons with co-occurring
substance abuse issues will be better served by outreach workers with a working familiarity with these
models. Workers are familiar with and provide linkage to community resources or support groups, when
the person begins to express interest. A Harm Reduction approach is generally the best engagement
strategy.

The main tenets of Harm Reduction are:

• a non-judgmental and respectful approach

• helping residents to identify harmful effects of drug and alcohol use and the benefits of decreasing
and/or ceasing use

• exploring alternate, safer routes and patterns of use

• praising small successes

• developing flexible plans that address substance abuse issues.

Common strategies successfully used to help addicted homeless persons include:

• Stabilization services like detox centers (McCarty, et al., 1990), inebriate reception centers (Bennett,
1990), and sobering-up stations (Bonham, et al., 1990) help to address immediate needs, provide
respite, and an entry to substance abuse services.

6-14 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

Case management services (McCarty, et al., 1990, Bonham, et al., 1990, and Willenberg, et al., 1990)

help link persons to services, provide support, and help clients reach decisions regarding their own

recovery. Persons can move back and forth between basic and intensive case management based on

their needs (Bonham, et al., 1990).

Jail liaisons (Bonham, et al., 1990) help explain services and link clients to them, identify those in

need of case management, track clients, and advocate for mandated treatment rather than

incarceration for revolving "public inebriates."

Vocational training (Bonham, et al., 1990 and Ridlen, et al., 1990) in a variety of areas is offered to

homeless men and women who are ready for such services.

Housing in conjunction with supportive services (Willenberg, et al., 1990 and Ridlen, et al., 1990)

are offered along with education in areas of housing management like tenant rights, budgeting, and

problem-solving. Families are further assisted in areas of childcare and linkage to schools (Ridlen, et

al., 1990).

Drop-in centers (Bennett, et al., 1990) which offer showers, meals, information and referral services,

on-site substance abuse services, benefits counseling, telephone, transportation, a warm, homelike

environment, and friendly faces.

Access to treatment (Bennett, et al., 1990). Successful programs reduce barriers for homeless

persons needing substance abuse treatment. This may include reserving a percentage of beds for

homeless persons, reducing waitlists, and improving inter-agency relationships.

Measurable Outcomes

Successful Outreach and Engagement Strategies

Studies have shown that outreach and engagement strategies, while initially time-consuming and slow-
moving, are successful because they reach more severely impaired persons who are less motivated to
seek out services (Lam and Rosenheck, 1998). Three month outcome data compiled via the ACCESS
study (Lam and Rosenheck, 1998), showed that clients reached in outreach on the streets experienced
improvement on nearly all outcome measures equivalent to clients who were contacted in other services
agencies and shelters. Outreach clients did equally well in areas of housing outcomes, quality of
housing, improved mental health and decrease of psychiatric admissions, substance abuse, employment,
social support, reduced victimization, and quality of life. This suggests that this hard-to-reach population
has the same capacity for improvement as groups more connected to services and who may be more high-
functioning.

The ACCESS program has demonstrated that people will use services if they are accessible and relevent
and that effective outreach will lead to an increase in access to other services. Although helping
homeless persons access mainstream services is difficult nationwide, ACCESS has shown that programs
with sufficient resources can help people to be successfully treated in a community setting and that the
bridge from homeless services to mainstream services is possible.

Positive housing outcomes, a major focus of homeless services, was also found by Bybee, et al., to be
linked to outreach services (1994 and 1995). The likelihood of success in independent living was
impacted by the amount of services, and a wide range of interventions and the intensity of those
interventions and services. Recruitment sources also impacted housing success, in that those recruited
from inpatient psychiatric settings were more likely to experience housing success than long-term
Community Mental Health clients, suggesting that greater stabilization possibilities follow acute
psychiatric episodes across populations. Anyone may have the opportunity for successful housing

National Symposium on Homelessness Research 6-15

To Dance With Grace: Outreach & Engagement To Persons On The Street

placement following a crisis. Those recruited from shelters also had greater likelihood of successful
independent living, but also may continue to live in temporary settings, suggesting the variance of the
degree to which persons from shelters can be easily housed. There was a smaller, yet significant
predictability between housing status and client functioning, symptomatology, and substance abuse
problems.

Quantitative Measures

Improvement is often so subtle that it doesn't register on typical functional improvement scales. One
program measures number of days per month spent in housing, number of times victimized, level of
hygiene, number of contacts with other service providers, and so on (Axelroad, 1987).

In some cases, quantitative measures can be deceptive, as evidenced in Barrow's 1988 survey. After a six
month survey of completed referrals, only a small minority were successful, such as only 24 percent of
entitlement referrals, 42 percent of housing referrals, and 13 percent of psychiatric referrals. While this
appeared to be a reflection of ineffective services, it also reflected a short study period, discrepancies
between client and program perceived needs, and lack of resources.

One outreach program measures success by four criteria: present living arrangement, receipt of financial
aid or other income, enrollment in a program for the treatment of alcohol abuse of mental illness when
appropriate, and receipt of treatment for other medical conditions. The first year's data suggest that about
four out of five persons have made at least one significant change (Rosnow, 1988).

Project Connect uses quantitative methods including face to face pre- and post-interview data with
clients, monthly program data on clients, self-administered pre- and post-questionnaire data for
community agency staff, and selected administrative record data from Project Connect agencies
(Bonham, et al., 1990).

As part of the continuum of care delivery, workers can implement successful strategies described in
Critical Time Intervention (CTI) to prevent recurrent homelessness and promote successful transitions to
housing. One component of CTI is to strengthen the relationship between the individual and family,
friends, and services, and secondly to provide emotional and practical support during the critical time
after discharge from a shelter. Outcomes of CTI included significant reduction in homelessness and a
preliminary indication that CTI is cost-effective (Jones et al., 1994, Susser, et al., 1997). Interventions
are short in duration, simple, can be implemented by nonprofessional staff, and can be implemented in
marginal settings (Susser et al., 1997).

A series of studies of homeless veterans by Rosenheck et al. (1989, 1993, 1995) evaluated the impact of
outreach programs for homeless veterans with mental illness and found that outreach services are
successful. The 1993 study found that outreach services increased access to outpatient and domiciliary
services and reduced inpatient services. The 1989 study found outreach to be successful in that a
significant number of homeless vets eventually wanted services and that outreach and advocacy efforts
enhanced access to health care services. Outreach services have been found to be costly although there
was a slight reduction in inpatient costs. Rosenheck, et al. (1995) caution that one cannot conclude, on
the basis of cost alone, that less expensive treatments should replace more expensive ones. Many
outreach programs have found that the initial cost of outreach and engagement pays off in the end.

6-16 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

Studies evaluating substance abuse programs found that offering an array of stabilization services along
with case management services, contributed to recovery and utilization of services (McCarty, et al., 1990,
Willenberg, et al., 1990, and Ridlen, et al., 1990).

Qualitative Measures

Qualitative measures are useful for service providers in evaluating program functioning (Axelroad,
1987). One helpful technique is questioning formerly homeless individuals who have been outreach
clients to find out which elements in the outreach team's approach were appealing or useful and which
were perceived as negative. Project Connect uses ethnographic observations, interviews, and journals
maintained by immediate program personnel (Bonham, et al., 1990). Qualitative evaluations can also be
helpful in demonstrating to potential funders the complex nature of clients, outreach efforts, linkages,
and length of engagement periods (Axelroad, 1987).

Challenges and Limitations In Determining Effectiveness

The very factors which contribute to a successful outreach effort — flexibility, ability to alter service
systems — may impede evaluations which strive to concretely measure their effectiveness (Axelroad,
1987). There is a lack of controlled studies that demonstrate effectiveness and a lack of longitudinal
studies. These are critical evaluation designs, yet are often difficult to implement with outreach clients
who may be difficult to track.

Evaluations aimed at measuring the overall effectiveness of an outreach program must focus on the
extent to which services and resources are available to outreach clients. In addition to evaluating
effectiveness of services provided by the program, programs must also determine who is not being served
by the program (Axelroad, 1987), why they are not being served, and how they might be served in the
future.

Successful outcomes are not necessarily related to program services and should be considered in
evaluating those programs. In one study, for example, success in obtaining housing and remaining
housed were found to be related to socioeconomic background, defined by education and past
employment, and level of functioning. Program services that were related to positive housing outcomes
included an early focus on entitlements and housing-related services and participation on the part of the
homeless person in defining housing goals were critical to their long-term success (Barrow, 1991).

While it is difficult to generalize outcome parameters across populations, regions, culture, and other
factors across the country, a standard set of street outreach outcome measures is desirable at the national
level. These standard outcomes should be different from standard outcomes used for other homeless
populations which may be unrealistic for outreach populations. Outcome standards should also be set by
individual programs. HUD requires Supportive Housing applicants to provide goals and objectives and
later the extent to which goals were attained.

Future research and programmatic goals might include: identifying what national homeless outreach
measureable outcomes might be; identifying specific factors that allow for successful transition from
homeless to mainstream systems for the general outreach homeless population and for specific
populations; the extent to which outreach teams are successfully used; the extent to which peer based
outreach models and consumer involvement in program planning, implementation, and evaluation are
successful; the development of more controlled and longitudinal studies; how the use of data-tracking
within information systems might be implemented ethically and effectively; incorporating outreach

National Symposium on Homelessness Research 6-17

To Dance With Grace: Outreach & Engagement To Persons On The Street

outcomes within the managed care system; and the cost-effectiveness of providing outreach services and
answering whether or not exemplary practices should be equated with effectiveness.

To Dance In A Bigger Ballroom — Toward Exemplary Practice At All Levels

There are effective strategies for influencing the adoption of exemplary practices and policies on each
major administrative level — agency, local community, state and federal. There are also many questions
still open for discussion. Outreach workers rarely can be successful unless exemplary practices exist at
other levels.

Agency

Effective administrators or program directors must educate the agency board about outreach activities
and philosophy and advocate on behalf of outreach staff at the board level. Directors must also support
the outreach team and advocate for their efforts with other service providers in the community;
(Axelroad, 1987; Wobido, 1990).

Outreach staff must be given flexibility in work schedules so they can seek out and find persons in the
evening and on weekends. Funds must be available for incentive and basic need items, as well as
equipment. Providing outreach workers with on-call medical and psychiatric consultants is critical as is
promoting a sense of teamwork — preferably a multi-disciplinary one. This helps workers feel supported
and provides them with tools with which they can provide better services. Exemplary agencies, with
outreach as a component, make provisions in service delivery for outreach clients, like allowing clients to
receive medical/ psychiatric/substance abuse services when needed rather than by appointment. They
allow bypassing of unnecessary forms and paperwork, and adopt the engagement stance.

Orientation and training of new outreach staff is critical particularly in the area of street safety. Training
should include: street safety, characteristics of the target population, substance abuse/dual diagnosis, the
criminal justice system, benefits and entitlements, community resources, involuntary hospitalization,
client rights, harm reduction, confidentiality, de-escalation, boundaries, CPR, basic first aid, regional
laws regarding child and elder abuse, engagement strategies, cultural competency, and infection control.
Safety training should require that new staff sign a document indicating that they understand safety
guidelines. This makes worker risks clear prior to hiring, while protecting the worker from injury and the
agency from future liability.

Outreach workers often feel a sense of isolation in the field, from other homeless and non-homeless
service providers and are likely to be viewed as marginalized themselves. As a result, agencies need to
ensure a system of support, advocacy, and inclusion for their outreach staff.

Exemplary agencies provide opportunity for ongoing discussion around ethical issues. Clinical
supervision and/or peer supervision is recommended for outreach staff who need to get second opinions
on implementation of their ideas to creatively engage persons. The question must always be asked, to
what extent are the engagement strategies used by workers non-coercive and non-deceptive (Lopez,
1996)? Supervision can also address issues like engagement versus enabling, boundaries, legal issues,
and service-provision.

Outreach workers sometimes get harassed and are discriminated against along with their clients. If
outreach workers function as service and/or rights advocates, their agency needs to determine which

6-18 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

parameters of advocacy efforts are allowed and encouraged. They should also develop positive
relationships with police and security personnel. Finally, outreach workers should attempt to develop
positive relationships with intake workers and staff at other agencies where they might refer clients.

Community

In addition to direct services, outreach workers and administrators can enhance the knowledge base of
effective outreach practices on a community-wide level, by providing consultation, education, training
and referrals (Morse, 1991; Slagg, et al., 1994). Outreach workers can start an "outreach coalition,"
sharing resources, ideas, information, client tracking efforts, and mutual support. This process is
essential in providing linkages to resources. In many communities, there are a dearth of resources, and
outreach workers end up providing intensive case management, in a continuous relationship model.

Outreach workers can share success stories — they encourage other workers, combat the community's
"compassion fatigue," and give hope to those clients still in crisis. Success stories are an essential part of
informing funders, politicians, and policy-makers that services work.

Outreach programs cannot be designed in isolation from other service programs (Axelroad, 1987; Morse,
1987; Barrow, 1988). Survival depends upon community networking: providing referrals, sharing
resources, pooling knowledge, and participating in community-wide groups (Nasper, 1992). In
discussing outreach, it is essential to discuss the gaps and barriers in these systems (Axelroad, 1987).
The most flexible, well-staffed and funded outreach program will have little impact if the mental health,
health, housing and social service systems in a community are not capable of serving people linked
through outreach efforts.

One urban outreach program made efforts to minimize coordination problems by expanding the makeup
of a coalition with representatives of human service organizations in both the public and private sector;
getting active participation with various planning and coordination bodies concerned with homelessness;
and structuring the outreach program so that the workers could become familiar enough with their
counterparts in other service-provider agencies (Rosnow, 1988).

Public-private partnerships can lead to effective service-provision. One example is the Times Square
Consortium (TSC). This is a partnering of the Times Square Business Improvement District and social
service agencies to provide outreach and a drop-in center for homeless persons in the Times Square area.
Rather than a business-community attempting to simply arrest and move along persons who are
homeless, they provided the impetus for social services. Together the TSC has applied for and received
funds from state and HUD (Porter, 1997).

Project Respond in Portland, Oregon, won the 1997 Gold Achievement Award by the American
Psychiatric Association for its exemplary outreach program. Exemplary community practices cited
include successful and collaborative relationships with "community partners" like police, housing
managers, service-providers, and businesses. Also cited was the reduction of stigma, seeking of missing
persons, consultation, community education, including police education, and diversion (Talbot, 1997).

These approaches are heartening in an apparent climate toward the criminalization of homeless people.
There has been an increase in anti-vagrancy laws which prohibit sitting, panhandling, or being in an
airport during certain hours. Outreach is one of the few formal contacts where service professionals
connect with homeless people who may be breaking laws. Outreach workers and their agencies could be
held legally accountable because of their association with these homeless persons.

National Symposium on Homelessness Research 6-19

To Dance With Grace: Outreach & Engagement To Persons On The Street

State/Federal

One outstanding issues that still needs to be addressed at the state/federal level is funding. Who should
pay for outreach? Through the Continuum of Care process, communities are encouraged to include
outreach as part of the continuum. On a national level, service-providers must advocate that managed
care plans make point-of-access exceptions for homeless persons, and the homeless Medicaid population
must be carved out of Medicaid managed care and financed separately (Plescia, 1997).

The cost-effectiveness of outreach programs often comes into question. One reason is related to the
comparison of numbers of people served on outreach versus the number of people served in homeless
shelters. If funders think of effectiveness in terms of the numbers of people served, then homeless
shelters will be viewed as more effective. The people outreach programs tries to serve are those who
don't readily come to and accept services and who need a period, sometimes a lengthy one, of
engagement. The positive outcomes of outreach services may not be readily seen. Yet, the cost of
providing outreach services may divert costs from other systems such as emergency rooms, hospitals,
psychiatric units, jails, and other crisis systems of care. This issue also reflects a structural obstacle to
demonstrating cost savings between systems. For example, at the federal level, HUD funds many
outreach programs, but the cost savings are realized in other systems such as Medicaid, the mental health
system and substance abuse system. The same obstacles to demonstrating cost savings exists at state and
community levels as well.

Agencies and communities need to ask what more could be done on a federal level to support outreach
programs. One possibility could be a requirement of outreach services in states' Medicaid plans. HUD
does not fund emergency services or prevention of homelessness, and perhaps they should. Another
possibility, could be a mandate that all Continuum of Care proposals include a strong outreach
component, with penalties if outreach is not included.

More publications and guidelines for outreach are needed. Federal departments charged with addressing
homelessness could provide "how to" information for service providers, and present options for service
delivery based on research findings. Exploration of the range of services could be done nationally to
determine specific trends related to successful outreach. Inquiry into what is optimal and what should be
expected of outreach programs can take place federally. For example, the authors are familiar with
outreach programs with a range of hours — from weekdays only to 7 days/week 16 hours/day. What have
we learned about optimal services delivery? Several cities combine outreach with police escorts. Does
this implied concern for worker safety in fact drive away potential clients and eliminate a Harm
Reduction approach? Expertise is needed in this area if outreach programs decide to try and build
collaborative relationships with police and security.

Homelessness among severely mentally ill persons, and chronic substance abusers represents a failure of
state and federal policy to adequately address or sustain long-term community support systems. Rather
than stimulating new funding mechanisms and service delivery systems, they should be preventing
homelessness by bolstering basic community resources for the long-term care of disabled persons
(Rosnow, 1988). In the long run, prevention efforts should be incorporated in structural measures to
prevent homelessness and provide appropriate services to those with chronic disabilities.

6-20 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

References

Most of the following references are found in the National Resource Center on Homelessness and Mental
Illness' Annotated Bibliography: Outreach Services to Homeless People with Serious Mental Illnesses.

Axelroad, S. E. & Toff, G. E. (1987). Outreach Services for Homeless Mentally III People.
Washington, DC: George Washington University.

Barrow, S. M. (1988). Delivery of Services to Homeless Mentally III Clients: Engagement, Direct
Service and Intensive Case Management at Five CSS Programs. New York, NY: New York State
Psychiatric Institute.

Barrow, S. M., Hellman, F., Lovell, A. M., Plapinger, J. D. & Stuening, E. L. (1991). Evaluating
Outreach Services: Lessons from a Study of Five Programs. In N. Cohen (Ed.), Psychiatric Outreach to
the Mentally III (New Directions for Mental Health Services), 52: 29-45.

Bennett, R. W., Weiss, H. L., & West, B. R. (1990). Alameda County Department of Alcohol and Drug
Programs Comprehensive Homeless Alcohol Recovery Services (CHARS). Alcohol Treatment
Quarterly, 7(1): 111-128.

Berman, S., Barilich, J. E., Rosenheck, R. & Koerber, G. (1993). The VA's First Comprehensive
Homeless Center: A Catalyst for Public and Private Partnerships. Hospital and Community Psychiatry,
44(12): 1183-1184.

Bonham, G. S., Hague, D. E., Abel, M. H., Cummings, P. & Deutsch, R. S. (1990). Louisville's Project
Connect for the Homeless Alcohol and Drug Abuser. Alcoholism Treatment Quarterly 7(1): 57-78.

Bronstein, L. R. (1996). Intervening with Homeless Youths: Direct Practice without Blaming the
Victim. Child and Adolescent Social Work Journal 13(2): 127-138.

Bybee, D., Mowbray, C. T., & Cohen, E. (1994). Short Versus Longer Term Effectiveness of An
Outreach Program for the Homeless Mentally 111. American Journal of Community Psychology 22(2):
181-209.

Bybee, D., Mowbray, C. T., & Cohen, E. H. (1995). Evaluation of a Homeless Mentally 111 Outreach
Program: Differential Short-Term Effects. Evaluation and Program Planning 18(1): 13-24.

Cohen, M. B. (1989). Social Work Practice with Homeless Mentally 111 People: Engaging the Client.
Social Work 34(6): 505-509.

Hibbs, J. R., Benner, L., Klugman, L., Spencer, R., Macchia, I., Mellinger, A. K. & Fife, D. (1994).
Mortality in a Cohort of Homeless Adults in Philadelphia. New England Journal of Medicine 331(5):
304-309.

Hopper, K., Mauch, D. & Morse, G. (1989). The 1986-1987 NIMH-Funded CSP Demonstration
Projects to Serve Homeless Mentally III Persons: A Preliminary Assessment. Rockville, MD: National
Institute of Mental Health.

Hwang, S., Orav, J., O'Connell, J., Lebow, J., & Brennan, T. (1997). Causes of Death in Homeless
Adults in Boston. Annals of Internal Medicine, 726(8): 665-628.

National Symposium on Homelessness Research 6-21

To Dance With Grace: Outreach & Engagement To Persons On The Street

Interagency Council on the Homeless. (1994). Priority: Home! The Federal Plan to Break the Cycle of
Homelessness. Washington, DC: U. S. Department of Housing and Urban Development HUD-1454-
CPD.

Interagency Council on the Homeless. (1991). Reaching Out: A Guide for Service Providers.
Washington, DC: Interagency Council on the Homeless.

Jones, K., Colson, P., Valencia, J. D., & Susser, E. (1994). A Preliminary Cost Effectiveness Analysis
of an Intervention to Reduce Homelessness Among the Mentally 111. Psychiatric Quarterly 65(4): 243-
256.

Lam, J., & Rosenheck, R. (1998). Street Outreach for Homeless Persons With Serious Mental Illness: Is
It Effective? Draft Report. Rockville, MD: Federal Center for Mental Health Services.

Leiberman, A. A., Gowdy, E. A., & Knutson, L. C. (1991). The Mental Health Outreach Project: A
Case Study in Self-Help. Psychosocial Rehabilitation Journal 14(3): 100-103.

Lopez, M. (1996). The Perils of Outreach Work: Overreaching the Limits of Persuasive Tactics. In
Dennis, D. & Monahan, J. (eds.) Coercion and Aggressive Communicy Treatment: A New Frontier in
Mental Health Law. Plenum Publishing Corporations, 85-92.

Marcos, L. R., Cohen, N. L., Narducci, D., & Brittain, J. (1990). Psychiatry Takes to the Streets: The
New York City Initiative for the Homeless Mentally 111. American Journal of Psychiatry 147(11).

Martell, J. V., Kobayashi, J., Seitz, R., Harada, J. (1992). The Honolulu Urban Homeless Project:
Mortality in an Urban Homeless Population. Honolulu: University of Hawaii, John A. Burns School of
Medicine. Unpublished. 1992.

Martell, J. V., Seitz, R. S., Harada, J. K., Kobayashi, J., Sasaki, V. K., & Wong, C. (1992).
Hospitalization in an Urban Homeless Population: The Honolulu Urban Homeless Project. Annals of
Internal Medicine, 776(4): 299-303.

McCarty, D., Argeriou, M., Krakow, M., & Mulvey, K. (1990). Stabilization Services for Homeless
Alcoholics and Drug Addicts. Alcoholism Treatment Quarterly 7(1): 31-45.

McMurray-Avila, M. (1997). Organizing Health Services for Homeless People: A Practical Guide.
Nashville, TN: National Health Care for the Homeless Council, Inc.

McQuistion, H. L., D'Ercole, A., & Kopelson, E. (1996). Urban Street Outreach: Using Clinical
Principles to Steer the System. New Directions for Mental Health Services, 52 (Winter): 17-27.

Mindell, A. (1988). City Shadows: Psychological Interventions in Psychiatry. London: Arkana.

Morse, G. ( 1 987). Conceptual Overview of Mobile Outreach for Persons Who are Homeless and
Mentally III. St. Louis, MO: Malcolm Bliss Mental Health Center.

Morse, G. (1997). Reaching Out to Homeless People Under Managed Care: Outreach and Engagement
to People With Serious Mental Illness Within the Changing Marketplace. Paper prepared for the
National Resource Center on Homelessness and Mental Illness, April.

6-22 National Symposium on Homelessness Research

To Dance With Grace: Outreach & Engagement To Persons On The Street

Morse, G. A., Calsyn, R. J., Miller, J., Rosenberg, P., West, L., & Gilliland, J. (1996). Outreach to
Homeless Mentally 111 People: Conceptual and Clinical Considerations. Community Mental Health
Journal, 32(3): 261-274.

Morse, G., Calsyn, R. J., West, L., Rosenberg, P., & Miller, J. (1991). Mental Health Outreach to the
Homeless: Conceptual and Clinical Considerations. St. Louis, MO: State of Missouri Department of
Mental Health (In Press).

Mullins, S. D. (undated). Steps Out: A Peer-Integrated Outreach and Treatment Model for Homeless
Persons with Co-Occurring Disorders. Rockville, MD: Substance Abuse and Mental Health Services
Administration.

Nasper, E., Curry, M., & Omara-Otunnu, E. (1991). Aggressive Outreach to Homeless Mentally 111
People. New England Journal of Public Policy 8(1): 715-727.

Plescia, M. Watts, R., Neibacher, S., & Strelnick, H. (1997). A Multidisciplinary Health Care Outreach
Team to the Homeless: The 10- Year Experience of the Montefiore Care for the Homeless Team. Family
and Community Health, 20(2): 58-69.

Porter, B. (1997). To Reach the Homeless. New York, NY: Times Square Business Improvement
District.

Ridlen, S., Asamoah, Y., Edwards, H. G., & Zimmer, R. (1990). Outreach and Engagement for
Homeless Women At Risk of Alcoholism. Alcoholism Treatment Quarterly 7(1): 99-109.

Rog, D. J. (1988). Engaging Homeless Persons With Mental Illness Into Treatment. Alexandria, VA:
National Mental Health Association.

Rosenheck, R., Frisman, L., & Gallup, P. (1995). Effectiveness and Cost of Specific Treatment
Elements in a Program for Homeless Mentally 111 Veterans. Psychiatric Services 46: 1 131-1 139.

Rosenheck, R., Gallup, P., & Frisman, L. K. (1993). Health Care Utilization and Costs After Entry Into
an Outreach Program for Homeless Mentally 111 Veterans. Hospital and Community Psychiatry 44(12):
1166-1171.

Rosenheck, R., Leda, C, Gallup, P., et al. (1989). Initial Assessment Data From A 43-Site Program for
Homeless Chronic Mentally 111 Veterans. Hospital and Community Psychiatry 40(9): 937-942.

Rosnow, M. (1988). Milwaukee's Outreach to the Homeless Mentally 111. In Assisting the Homeless:
State and Local Responses in an Era of Limited Resources. Washington, DC: Advisory Commission on
Intergovernmental Relations.

Shapiro, J. P., Kalb, D., Golden, S. F., Dzik, E., Hawkins, S. L., Ellis-Simons, P. (1988). Hope for the
Homeless. U. S. News and World Report, Feb. 29.

Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W., & Wyatt, R.J. (1997). Preventing Recurrent
Homelessness Among Mentally 111 Men: A "Critical Time" Intervention After Discharge From a Shelter.
American Journal of Public Health 87(2): 256-262.

National Symposium on Homelessness Research 6-23

To Dance With Grace: Outreach & Engagement To Persons On The Street

Talbot, J. A. (Ed). (1997). Gold Award: Linking Mentally 111 Persons with Services Through Crisis
Intervention, Mobile Outreach, and Community Education. Psychiatric Services 48(1 1): 1450-1453.

Task Force on Homelessness & Severe Mental Illness. (1992). Outcasts on Main Street. Washington,
DC: Interagency Council on Homeless.

Van Tosh, L. (1990). Final Report and Evaluation of Outreach, Advocacy and Training Services for the
Mentally III Homeless (Project OATS). Philadelphia, PA: Project SHARE.

Wasmer, D. (1998). Engagement of Persons Who Are Homeless and Have a Serious Mental Illness: An
Overview of the Literature and Review of Practices By Eight Successful Programs. De Paul University,
Master's Thesis.

Weinreb, L., Browne, A.., & Berson, J. D. (1995). Services for Homeless Pregnant Women: Lessons
From the Field. American Journal of Orthopsychiatry 65(1): 491-501.

Willenbring, M. L., Whelan, J. A., Dahlquist, J. S., & O'Neal, M. E. (1990). Community Treatment of
the Chronic Public Inebriate I: Implementation. Alcoholism Treatment Quarterly 7(1): 19-91 .

Winarski, J. (1998). Outreach Services. Presentation on Implementing Interventions for Homeless
Individuals with Co-Occurring Disorders. April 23.

Winarski, J. T. (1994). Providing Outreach Outside the Shelter. In Bassuk, E., Birk, A., & Liftik, J.
(eds.), Community Care for Homeless Clients with Mental Illness, Substance Abuse, and Dual Diagnosis.
Newton, MA: The Better Homes Fund.

Wobido, S. L., Frank, T., Merritt, B., Orlin, S., Prisco, L., Rosnow, M., & Sonde, D. (1990). Outreach.
In Bricknew, P. W., Scharer, L. K., Conanan, B. A., Savarese, M., & Scanlan, B. C. (eds.), Under the
Safety Net: The Health and Social Welfare of the Homeless in the United States. New York: NY: W.W.
Norton & Company.

6-24 National Symposium on Homelessness Research

A Review of Case Management for People Who Are
Homeless: Implications for Practice, Policy, and Research

by
Gary Morse, Ph.D.

Abstract

Case management programs for homeless people have proliferated since the 1980s but some have
questioned the meaning and clarity of the term case management while others have questioned its
effectiveness for serving clients. This paper first attends to conceptual issues, identifying primary
functions and process variables for understanding and describing case management services. The paper
next describes models and approaches to case management for various client subgroups and specialty
areas.

The paper also reviews the empirical literature on homelessness and case management, especially as it
relates to treatment effectiveness and critical factors. Several conclusions are postulated, including that
some case management approaches, especially assertive community treatment (ACT), are effective for
helping people who are homeless with severe mental illness; frequent service contact is a critical
ingredient leading to positive treatment retention and housing outcomes; case management is more
effective with some clients than others. A number of gaps in our knowledge of case management are also
identified.

The final section of the paper presents recommendations on exemplary practices. These include
recommendations related to critical staff skills and abilities, service principles, case management models,
and organizational practices.

Lessons for Practitioners, Policy Makers, and Researchers

Recommendations for homeless case management practitioners include focusing service delivery efforts
upon:

Conducting assertive, community-based outreach;

Nurturing trusting, caring relationships with clients;

Respecting client autonomy;

Prioritizing client self-determined needs;

Providing clients with active assistance to obtain needed resources;

Maintaining small case loads; and

Implementing ACT approaches.

The federal government is also encouraged to promote exemplary practices through knowledge
dissemination, advocacy, and financing actions and to promote new research and knowledge on case
management services for people who are homeless.

National Symposium on Homelessness Research 7-1

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Introduction

Within the past two decades, case management has functioned as a cornerstone of efforts to serve people
who are homeless. During that period, providers and researchers have recommended case management
services for homeless people, policy makers have facilitated the development of case management
programs through grant announcements, and Congress has encouraged States to provide case
management through legislative initiatives (McKinney Act, PATH, mental health block grants). Program
developers have adapted case management services for a variety of subgroups of homeless people,
including those with severe mental illness, substance abuse disorders, people with dual diagnoses,
pregnant women, and homeless families. Case management services need to be considered within a
broad perspective that recognizes the multiple and serious needs of people who are homeless, the varying
subgroups, the need for multiple interventions at various levels of society, and the crucial importance of
adequate housing resources (Dennis et al., 1991; Federal Task Force on Homelessness and Severe Mental
Illness, 1992; Morse, 1992). Undoubtedly, however, case management has become in practice one of the
most common services to people who are homeless.

Why have case management services been recommended and implemented so frequently in the area of
homelessness? In part, there is a general Zeitgeist of case management within human services. More
specifically, however, the initial development of case management services has resulted in part from
several interrelated, key assumptions about the problems, causes, and solutions of homelessness:

1 . People who are homeless have serious and multiple problems and unmet service needs and problems
(Ball & Havassy, 1984; Morse & Calsyn, 1986).

2. The services and resources necessary to met these human needs are contained within a fragmented
system of disparate service organizations (Rog, 1988).

3. Additionally, the service system is often structured and operated in such a manner that it poses a
number of obstacles and barriers for clients in need; clients, therefore, often have difficulty accessing
needed services and resources (Goldfinger & Chavatz, 1984; Rog et al., 1987).

4. Case managers are thought to be necessary to "facilitate access," "coordinate," "negotiate," and
ensure services for client needs (e.g., Francis & Goldfinger 1984; Levine & Fleming; 1986; Oakley
& Dennis, 1996; Rog et al., 1987).

Note the service system function inherent in these assumptions. As Hopper, Mauch, and Morse (1989),
framed it, case managers perform "microsurgery on the service system." Not surprisingly, some have
considered case management to be one intervention strategy for changing and improving the entire
service system as well as improving individual client outcomes (Mechanic, 1991; Raif & Shore, 1993;
Surles, Blanch, Shern, & Donahue, 1992).

An additional set of beliefs about people who are homeless also facilitated the development of case
management programs. Specifically, homeless people have often been described as markedly mistrustful
and suspicious of service providers, and to highly value their autonomy (e.g., Francis & Goldfinger,
1986). Case managers have been conceptualized as workers whose first task is to engage people who are
homeless, developing and nurturing trust and a working alliance (Francis & Goldfinger, 1986).

7-2 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

While compelling arguments have been for case management services, significant questions and concerns
have also arisen. Confusion about exactly what constitutes case management has been common. Others
have questioned the effectiveness of case management.

The remainder of this paper will attend to these and related issues. Specifically, the following sections
will:

• Discuss definitional and conceptual issues related to case management.

• Identify and briefly discuss different case management models or approaches used with homeless
clients.

• Review the research literature related to the empirical study of case management approaches for
people who are homeless, with a special emphasis upon the effectiveness of case management
services. Conclusions will also be discussed and knowledge gaps identified.

• Draw from the literature to identify exemplary case management practices with people who are
homeless. This section will also provide recommendations about how agencies can promote
exemplary services.

• Conclude by providing additional recommendations on ways the federal government can promote
exemplary practices.

Definitional and Conceptual Considerations: What is Case Management?

Across all health and human services, case management remains a loosely defined service which is less
well understood than one might expect, given its widespread application and popularity" (Willenbring,
Ridgely, Stinchfield, & Rose, 1991, p. 14). This statement applies equally to the field of homelessness,
where case management has been characterized as "a much discussed but poorly defined concept"
(National Resource Center on Homelessness and Mental Illness, 1990, p. 1). The conceptual confusion
has resulted in part from a lack of definitional specificity. In the past decade, some theorists and
researchers have focused increased attention on conceptualizing and defining case management (e.g.,
Raif & Shore, 1993; Willenbring et al., 1991). Particularly useful is the review and conceptualization of
Willenbring and colleagues. They suggest that case management services can be defined in terms of their
specific service functions. They identify six primary functions that characterize case management (see
also Joint Commission on Accreditation of Hospitals, 1979):

• Client identification and outreach: to attempt to enroll clients not using normal services

• Assessment: to determine a person's current and potential strengths, weaknesses and needs

• Planning: to develop a specific, comprehensive, individualized treatment and service plan

• Linkage: to refer or transfer clients to necessary services and treatments and informal support
systems

• Monitoring: to conduct ongoing evaluation of client progress and needs

• Client advocacy: to intercede on behalf of a specific client or a class of clients to ensure equity and
appropriate services

They also note four additional functions which are common but variable across case management
services:

• Direct service: provision of clinical services directly to the client

National Symposium on Homelessness Research 7-3

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

• Crisis intervention: assisting clients in crisis to stabilize through direct interventions and mobilizing
needed supports and services

• System advocacy: intervening with organizations or larger systems of care in order to promote more
effective, equitable, and accountable services to a target client group

• Resource development: attempting to create additional services or resources to address the needs of
clients

Another common additional function of case management is discharge planning. Discharge planning
often incorporates many of the above functions as case managers help clients plan to transition from one
type of setting or service program to another.

The description of functions helps to provide more specificity to the definition of case management.
However, as Bachrach (1992) noted in the broader area of mental health services, there is still a lack of
consensus "about the precise meaning of case management" (p. 209; see also Rog et al., 1996). In part,
this results from the practice of a number of different models or approaches to providing case
management. Different case management models generally (but not always) perform the primary
functions identified above; however, they vary not only in the presence or absence of the additional
functions listed above, but also in other important ways. Especially important are the operational or
process characteristics of case management programs, which Willenbring and colleagues distinguish
from the functions of case management. The process characteristics measure more how case
management services operate, rather than what they do. The following list of seven process variables,
selected and modified from Willenbring and colleagues, are relevant for understanding similarities and
differences between specific case management services.

Duration of services (varying from brief, time limited to ongoing and open-ended)

Intensity of services (involving frequency of client contact, and client-staff ratios)

Focus of services (from narrow and targeted to comprehensive)

Resource responsibility (from system gatekeeper responsible for limiting utilization to client

advocate for accessing or utilizing multiple and frequent services)

Availability (from scheduled office hours to 24-hour availability)

Location of services (from all services delivered in office to all delivered in vivo)

Staffing pattern (from individual case loads to interdisciplinary teams with shared caseloads).

In addition to these seven variables related to how case management programs operate, it is useful to
consider who is involved in case management:

• Who is the client target population?

• Who are the staff, and especially what are their disciplines?

Case Management Approaches and Models

Table 1 provides a listing of case management models and approaches which have been described in the
published scientific or practice literature (or included in widely circulated government monographs or
reports). The phrase models and approaches are used to include both (a) programs that are well-
established in theory or research as well as (b) programs that represent emerging methods that are
commonly used in clinical practice, even in the absence of an extensive, preexisting theoretical or
research basis. Table 1 includes data, where available, considering several of the key operational or
process variables described above. These case management approaches are briefly described below

7-4 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

under five client subgroups: people with severe mental illness, people with severe mental illness and co-
occurring substance abuse disorders (dual diagnoses), people with substance abuse disorders, people with
primary health disorders, and homeless children and families. The majority of the published literature
concerns case management approaches for people with severe mental illness; thus, the following
discussion is more developed in this area, and, unfortunately, underdeveloped in other areas.

Severe Mental Illness

As shown in Table 1, intensive case management (1CM) approaches (see Rog et al., 1987) have been
widely used with a variety of homeless subpopulations, including people with substance abuse disorders,
homeless families, and especially with people with severe mental illnesses. ICM is illustrative of an
approach that has emerged from the field in the absence of an extensive, preexisting theoretical or
research basis. Its popularity for homeless clients has in part probably arisen from clinical principles-
assertive and persistent outreach, reduced case loads, active assistance in accessing needed resources-
that are compelling given the nature of clients' needs and system characteristics. Not surprisingly,
however, ICM approaches are sometimes mentioned without extensive description of their programmatic
functions or process characteristics. Further, the comparability of ICM across programs or homeless
subgroups is unclear and questionable; there appears to be significant operational differences across ICM
programs but these are often not systematically described or assessed.

Assertive community treatment (ACT) programs represent another common approach for homeless people
with serious mental illness. (For this review, the ACT approach is meant to encompass programs
identified in the literature as Continuous Treatment Teams or CTTs. The terms ACT and CTT are
sometimes may represent subtle programmatic differences but often in practice and research they are
synonymous terms, or indistinguishable from one another.) The ACT model has been highly researched
and well-established as an effective community-based intervention for non-homeless people with severe
mental illness (see Stein & Test, 1985; Burns & Santos, 1995). It has also been widely disseminated
throughout a number of states as a model program for some people with severe mental illness (Deci et al,
1995). ACT proponents eschew the term case management (e.g., Stein, 1992); despite the validity of
these objections, ACT is often included within reviews of case management and will be considered
within this rubric in this paper as well. The model does indeed differ significantly from many case
management approaches, especially in its emphasis on direct treatment and services, shared caseloads,
and use of an interdisciplinary team that includes specialists such as psychiatrists and nurses.

The ACT model has been adapted in various ways to improve its relevance to a homeless population.
These adaptations parallel many of the principles followed by homeless outreach and ICM programs;
they include assertive outreach, engagement strategies, and an increased emphasis on clients' resource
and housing needs (Dixon et al., 1995; Morse et al., 1992). Investigators have also added new
innovations to the basic ACT model by adding both adjunct lay citizen community workers (Morse et al.,
1997) and mental health consumers (Dixon et al., 1994) to the treatment team. Despite these
modifications, one advantage to the ACT approach is its clarity and specificity in program principles,
functions, and operations. The model is well described, and researchers have developed an instrument to
measure the degree of fidelity of any one program to the ideal ACT program (McGrew & Bond, 1995;
Teague et al., 1998). ACT teams for homeless clients with severe mental illness have recently been
widely promoted and replicated through the CMHS ACCESS program (Johnsen, Samberg, Calsyn,
Blasinsky, Landow, & Goldman, 1998).

National Symposium on Homelessness Research 7-5

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

A review of the literature (see also Table 1) suggests that a number of other case management approaches
have also been developed for homeless people with serious mental illness. In addition to ICM and ACT
approaches, two additional models are Clinical Case Management and Social Network Case
Management. Both provide sound theoretical justifications for their clinical and social network
components, respectively, while also incorporating basic ICM principles and characteristics. At present,
however, neither model appears to be widely practiced.

The Strengths Model is often advocated and implemented for the broad (non-homeless) population of
people with severe mental illness (Rapp, 1993). Features of this model include a focus on the
environment as well as the individual client, use of paraprofessional staff, emphasis on client strengths
rather than deficits, and a priority placed on following client directed interventions. The Strengths Model
has recently been implemented in a large demonstration for homeless clients in Kansas under the
ACCESS grant (Johnsen et al., 1988).

The Critical Time Intervention (CTI) is a new approach developed and tested for people who are
homeless with severe mental illness (Susser, Valencia, Conover, Felix, Tsai, and Wyatt, 1997). The CTI
approach focuses upon strengthening a person's long-term ties to other services and supports while
providing emotional and practical support during the critical period of a transition from shelter to
housing.

Also appearing within the literature are approaches which are noteworthy for their use of consumers as
case management staff. The use of consumers and peers has been incorporated within various models of
case management, including homeless ACT teams that include a consumer advocate (Dixon et al, 1994)
and ACT teams which are almost exclusively comprised of consumer staff (see Herinckx, Kinney,
Clarke, & Paulson, 1997). Consumer Case Management approaches have advocacy support, offer
important work roles for former patients, and may be helpful for engaging clients suspicious of
traditional mental health providers.

Finally, Broker Case Management approaches, meanwhile, are also commonly provided. Broker models
emphasize assessment, planning, referral, and monitoring functions without extensive outreach, linkage
or direct service contacts. While common, they are not recommended for homeless clients (Morse,
Calsyn, Klinkenberg, Trusty, Gerber, Smith, Templehoff, & Ahmad, 1997).

Dual Diagnosis

Many case management programs for homeless people with severe mental illness have also served large
number of persons who also have a co-occurring substance abuse disorder. Often, this has been a defacto
rather than planned intervention, given the high prevalence of co-occurring substance abuse disorders
among homeless people with severe mental illness (Federal Task Force on Homelessness and Severe
Mental Illness, 1992). More recently, there have been increased efforts to address the specialized needs
and problems of people with these dual diagnoses, especially among the non-homeless dually diagnosed
population (e.g., Durell, Lechtenberg, Corse, & Frances, 1993; Jansen, Masterton, Norwood, & Viventi,
1992; Jerrell & Ridgely, 1995; Osher & Kofoed, 1989; Young & Grella, 1998). These services often
follow the principles of Integrated Treatment (e.g., Mercer, Mueser, & Drake, 1998; Minkoff & Drake,
1991), which focuses upon an interdisciplinary, concurrent treatment approach to substance abuse,
mental health, and other related client needs. A recent review of the treatment outcome research for all
dually diagnosed clients recommended that integrated treatment approaches be comprehensive and
incorporate assertive outreach, case management, individual and group and family interventions, while

7-6 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

assuming a longitudinal, step-wise motivational enhancement approach to substance abuse treatment
(Drake, Mercer-McFadden, Mueser, McHugo, & Bond, in press).

There have been relatively few case management interventions for dually diagnosed homeless persons,
although there is a recent trend toward increased program development and research. The literature
includes an example of social network therapy/intensive case management which promotes referral and
linkage to existing substance abuse treatment providers rather than integrated treatment (Kline, Harris,
Bebout, & Drake, 1991). Additional publications describe integrated treatment-case management
approaches for homeless clients. Blankertz and White (1990) described a model of case management
incorporated within a residential program for dually diagnosed homeless clients. In this model, case
managers provided initial outreach and engagement, individualized service and rehabilitation planning,
linkage for needed resources and services, and facilitated psychoeducational substance abuse treatment
groups. Case management services were designed to follow clients whether or not they successfully
completed the residential program. Intensive/clinical case management programs (Drake et al., 1997)
and ACT programs (Meisler, Blankertz, Santos, & McKay, 1997) have also been modified to incorporate
integrated treatment concepts and methods for people who are homeless and dually diagnosed.
Additional projects are currently under development and research.

Substance Abuse

Case management is regarded as an important component in substance abuse services but there are few
studies specifying program models and elements (see U.S. DHHS, 1992). Similarly, case management
approaches have also been recommended and implemented for homeless clients with substance abuse
problems, although apparently not with the same frequency as for homeless people with serious mental
illness. Notable exceptions were three homeless case management demonstration programs funded by
NIAAA. McCarty, Argeriou, Krakow, and Mulvey (1990) designed and described an intensive case
management service in Boston as a key component within a stabilization project for homeless people
with substance abuse disorders. The intensive case management service was designed to assist clients
overcome their distrust of service providers, coordinate needed treatment and support needs, and "guide
them along the recovery continuum" (p. 39). The case management role emphasized linkage and
monitoring activities as well as support. Similarly, in the Louisville project, Bonham, Hague, Abel,
Cummings, and Deutsch (1990) emphasized the role of intensive case managers in the Louisville project
as connecting clients with community resources, especially AA and NA meetings, rather than as direct
service provision. The Louisville project followed other common case management practices (e.g.,
individualized planning, monitoring) while also focusing on the need for outreach. The Minneapolis
project, meanwhile, adapted the ACT model to serve homeless people considered as chronic public
inebriates (Willenbring, Whelan, Dahlquist, & O'Neal, 1990). This team was designed to provide
services and continuity of care in addition to conducting assessments, planning, and other common
functions. It is important to note that the above descriptions reflect the intended program models; in
actual practice, some significant discrepancies occurred (high client to staff ratios, considerable staff
turnover, and other implementation problems-see above references as well as Orwin et al., 1994, and
Willenbring et al., 1991).

Primary Health

Case management for homeless people has also been recommended as an effective strategy for enhancing
and supplementing primary health care services (Savarese et al., 1990; Stephens et al., 1991). In practice,
case management has been an important element in Health Care for the Homeless projects across the

National Symposium on Homelessness Research 7-7

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

United States (Savarese et al., Stephens et al). However, few detailed descriptions appear in the
literature concerning the specifics of homeless health care case management services. Savarese and
colleagues have illustrated how core case management functions have been integrated within normal
homeless health care teams activities in a myriad of ways. Stephens and colleagues, meanwhile, also
emphasize the integration of case management within a multidisciplinary team, while stressing the
importance of a case manager to monitor and broker the system. They also argue that:

health care providers need to focus more on case management activities, which may
include activities not necessarily associated with the provision of health care services
(for example, finding and providing food, clothing, shelter, and accessing entitlement
eligibility) to achieve the ultimate goal-stabilization-and when possible, reintegration of
the homeless person back into society (p. 15).

Kuczenski (1992), writing about a Health Care for the Homeless project in Minnesota, provides one
illustration of how nurses can perform outreach and follow-up home visits to provide support and help
clients with parenting and accessing needed resources. Steward (1992), meanwhile, described the role of
specialized case managers in the same HCH project in helping homeless people set and keep health
appointments, track specialized health information (e.g., immunization records), and access new
resources as they transition into stable housing.

In general, however, the literature, lacks detailed models of case management with primary health,
especially for specialized client subgroups. Homeless children have been identified as one high risk
group in need of intensive case management health services (Roth & Fox, 1990). More attention is also
needed for homeless people with poly-disorders, such as mental health, substance abuse, and HIV or
AIDS; one such project stresses the importance of case management in creating linkages across multiple
systems of care (Brindis, Pfeffer, & Wolfe, 1995). Worley and colleagues (1990) recommendations for
integrated approaches for non-homeless people with severe mental illness appear equally applicable to
homeless people with severe mental illness. Specifically, case management teams, such as ACT teams,
could incorporate psychiatric nurse specialists to perform health screenings, health monitoring, education
and disease prevention activities, while performing specialized medical linkage and coordination
functions with other providers. Nurse practitioners could also be employed for providing primary care as
well medical referral and monitoring.

Homeless Children and Families

Although the literature is very limited, case management services for homeless children and families
should be considered on the basis of the specific subgroup targeted for services. Specifically, case
management services have been described for young children (Carman, 1991); runaway and homeless
youths (Cauce, Morgan, Shantinath, Wagner, Wurzbacher, Tomlin, & Blanchard, 1993; Yates,
Pennbridge, Swofford, & Mackenzie, 1991), including pregnant teens (Borgford-Parnell, Hope, &
Deisher, 1994); and the entire homeless family (Rog et al., 1996).

Bassuk (1991) noted "there is a shortage of innovative programs" nationwide for homeless children. The
Kidstart Program was developed as a case management model for homeless children by the Better Homes
Foundation and IBM (Carman, 1991). There is a special emphasis on case managers engaging and
networking the various agencies involved with homeless children (shelters, schools, social services) and
in assessing the developmental progress and delays of young homeless children in social, emotional, and
cognitive domains. Kidstart incorporates common features of most case management programs including

7-8 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

service planning, linkage, and monitoring. Similar to other approaches for homeless people, Kidstart
emphasizes personalized and comprehensive care (Bassuk, 1991).

Two programs for runaways and homeless youths implemented intensive case management programs
(Borgford-Parnell et al., 1994; Cauce et al., 1993). The program by Cauce and colleagues was guided by
a comprehensive focus, recognizing "that although many of these youths have mental health problems,
their problems do not begin or end there" (p. 34). Emphasis was also placed on providing emotional
support and nurture, assisting clients to master developmental tasks, active involvement in the multiple
systems affecting adolescents, and intervention and support for the utilized social support networks of
clients, which often involved peers. The specialized intensive case management program for pregnant
homeless teens employed both nurses and social workers (Borgford-Parnell et al., 1994). In addition to
providing health and social services the program philosophy stressed outreach and engagement,
employing "unique strategies ... to meet the complex and ever changing needs of this difficult-to-serve
population" (p. 1030), building a trusting relationship, providing services in the field, concrete and active
assistance, consistent support, and long-term interventions. Services included health assessments, social
service assistance, and skill training and assistance with infant care. In addition to these mobile intensive
case management programs, case management services connected with long-term residential shelters
have also been developed for homeless teens (Yates et al.).

As Rog and her colleagues (1996) noted, despite its increasing popularity, there has been little explicit
study of case management's operations or effectiveness with (homeless) families (p. 68). Rog et al.'s
description of a joint Robert Wood Johnson Foundation and HUD initiative provides a rare discussion of
case management services for homeless families. The project recommended intensive case management
for families with intensive support, frequent in vivo contacts, on going services, and close linkages with
housing services (Rog et al., 1996).

Research Findings: What We Know and What We Don't Know

This section of the paper reviews the empirical research on case management for homeless people in four
areas: treatment specification and implementation evaluation, effectiveness, cost-effectiveness, and
critical factors influencing client outcomes. Subsequently, the paper will summarize conclusions from
the research about our knowledge of case management services for homeless people and also highlight
gaps in the current knowledge base.

Treatment Specification and Implementation Evaluations

Programs need to be carefully described and measured in order to understand the nature of the
intervention, properly interpret results, and assist replication efforts (e.g., Brekke, 1988). This is
especially relevant for case management programs, given the considerable confusion and uncertainty in
the field about the meaning of a case management program and since there are rarely pure models in
actual practice. It is also important to evaluate how closely an operation measures to an ideal model or
the intended program, since negative findings may result from implementation deviations rather than an
ineffective model. Unfortunately, however, many case management interventions are poorly described,
and fewer are observed or measured (for notable exceptions, see Johnsen et al., 1998; Mercier & Racine,
1991; Rog etal., 1996).

Specifying the treatment and measuring its implementation may reveal surprising if sometimes disturbing
insights. Rog and colleagues, for example, found in a large multi-site study that an intervention intended

National Symposium on Homelessness Research 7-9

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

as an intensive case management approach (with frequent client contact) actually only produced an
average of 15 hours of direct client services and 15 client contacts during the first year of service.
Similarly, First, Rife, & Kraus (1990) found that within a demonstration intensive case management
program that "37 percent of the clients received either minimal or no linkage with needed services" (p.
90; see also Barrow et al., 1996). Also, Johnsen and colleagues (1998) adapted a standardized instrument
measuring the treatment fidelity of six ACT programs and seven "modified" ACT programs included in
the ACCESS demonstration grant. They found, however, several significant deviations from the ideal
ACT model (time-limited instead of ongoing service commitment; lack of multidisciplinary staff) and
that "(n)one of the programs . . . achieved fidelity scores as high as the traditional ACT programs" (p.
17).

Treatment Effectiveness

Experimental Studies. All other research variables being constant, the most valid conclusions about the
effectiveness of case management services must be derived from experimental studies using random
assignment. Table 2 summarizes ten completed randomized studies assessing the effectiveness of case
management approaches for homeless people. Note that all ten studies involved homeless clients who
had serious mental illness (some persons also had a co-occurring substance abuse disorder).

Eight of the ten studies found that positive client outcomes occurred for the experimental case
management approach. In seven of these eight studies, the significant results included less time spent
homeless/more days stably housed in the community (the other study measured only treatment
engagement and retention and not housing outcomes). Five of the six studies using an ACT approach
found positive client outcomes. ACT interventions also sometimes produced other positive outcomes,
such as improved service utilization or treatment retention and reduced psychiatric symptoms.

Two of the three intensive (or assertive) case management approaches reported positive outcomes
(improved housing and, from one study that included psychosocial rehabilitation services, reduced
symptoms). The one study of the CTI approach found positive outcomes on the housing/homelessness
variables.

Note that the above paragraph summaries the differential treatment effectiveness of the case management
approaches against comparison treatments, which in some cases were other case management program.
In addition, several studies reported time effects whereby clients in all conditions improved over time in
certain areas, but without differential effectiveness between the experimental case management approach
and the comparison services (see Table 2). These improvements over time included positive outcomes in
family contacts, life satisfaction, income, self-esteem, and interpersonal adjustment. The use of other
treatment comparison groups makes the interpretation of these results unclear. Case management-as
well as the comparison conditions-may in fact be affecting these positive client outcomes, but they are
difficult to detect without a no-treatment control group.

Quasi- Experimental Studies. In addition to the experimental studies, some investigators have studied
the effects of case management interventions using quasi-experimental designs, including comparison
groups without random assignment, simple pre-post-analysis, and retrospective reviews. The findings
from such studies, however, should be considered much more cautiously, given a number of possible
threats to the validity of the conclusions that are inherent in non-experimental designs (see Cook &
Campbell, 1979). Table 3 summarizes eight homeless case management studies (one involved three
separate projects) relying upon non-experimental designs or analyses. As shown, four of these studies

7-10 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

involved subjects with severe mental illness, three with dually diagnoses subjects, and one (analyzing the
three separate NIAAA projects) involved persons with substance abuse disorders.

Three of the four studies involving people with severe mental illness used ICM approaches, the fourth
used ACT. The ACT study reported improvements in a number of areas, including in residential
stability, social adjustment, vocational functioning, and decreased symptoms. The three ICM studies
reported housing rates ranging between 5 1 percent and 63 percent over one year to 27 months assessment
intervals. A relatively high rate (71 percent) of mental health service utilization was reported in one
study, but two studies found surprisingly low rates of retention in case management services over time
(30 percent in one study, 16 to 57 percent depending upon the criterion in another).

The three studies of services for dually diagnosed clients each integrated substance abuse services into
mental services (one project used ACT, the other ICM/social network and clinical case management
models and the third a combined residential and case management program.) The ACT and CCM/Social
Network studies both reported some positive findings, especially for improved housing stability, but only
equivocal or minimal effects for substance abuse. The case management-residential program clients
were more likely than comparison clients to achieve successful discharge on a composite variable related
to stable housing, abstinence, and absence of rehospitalization; however, the overall rate of success was
still low (29 percent to 8 percent).

Orwin and colleagues (1994) reported on three NIAAA-funded research demonstration projects involving
case management interventions for homeless people with substance abuse problems. Using multivariate
analysis, Orwin et al. found evidence of significant treatment effects for only one intensive case
management intervention on housing permanence and independence variables. This same study showed
equivocal results and time-limited results on economic, employment, and substance abuse variables. In
the other two case management studies, Orwin and colleagues found at best minimal or equivocal results.
Orwin et al., however, noted that the absence of more powerful results may have resulted from a number
of research design and methodological problems (e.g., differential attrition) or from ineffective or low
intensity case management approaches.

Cost-Effectiveness

This review of the literature found only one completed study on the cost-effectiveness of any case
management approach for homeless people (Wolff, Helminiak, Morse, Calsyn, Klinkenberg, & Trusty
1997). Wolff and colleagues were able to collect cost data for a subsample of clients involved in the
randomized design of three conditions: ACT-only, ACT with community workers, and broker case
management (Morse et al., 1997). Results found that there were no significant costs differences between
the three programs when a comprehensive cost analysis was conducted although the ACT programs
produced better client outcomes (client contact, psychiatric symptoms, and client satisfaction); thus, both
ACT interventions were more cost-effective than broker case management.

Critical Factors

Service Factors or Mediators. The research literature provides some support for the proposition that at
least certain case management approaches, especially ACT, are effective ways of serving homeless
people, especially those with serious mental illness. A subsequent question then arises as to whether
there are particular factors that are critical for the success of effective case management interventions.
From a research perspective, one of the best and most rigorous methods for answering this question is to

National Symposium on Homelessness Research 7-11

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

conduct process evaluations that use multivariate analyses to specify the mediating variables or critical
ingredients that are correlated with positive client outcomes within experimental studies showing positive
effects. Unfortunately, very little of this type of research has been conducted in this field. Process or
correlational analyses from quasi-experimental and simple pre-post studies also provide some useful
information, though there are more possible threats to the validity of the conclusions. Table 4 provides
information on five experimental and quasi-experimental studies providing data on service factors that
may lead to positive client outcomes. It is worth noting that across three studies, frequency of contact
was associated with better client outcomes, specifically in the areas of housing stability (Barrow et al.,
1996), retention in case management and housing (Rife et al., 1991), and positive client satisfaction
(Morse et al., 1994). More frequent supportive services and mental health service contacts were
associated with both stable housing and also positive client satisfaction (Morse et al.).

Client Characteristics or Moderators. A related question asks: what client characteristics moderate
client outcomes? The answers to the question are important in order to identify clients who may be at
high risk of poor outcomes and where further service innovations may be necessary to develop more
effective approaches. Table 4 also describes six homeless studies that have identified client
characteristics associated with outcomes. Four findings have occurred in two or more studies:

• Lower lengths of time homeless are sometimes associated with better housing and treatment retention
outcomes

• Clients with fewer psychotic symptoms tend to have better outcomes

• Women tend to have better outcomes

• Clients without substance abuse problems tend to have better housing and treatment retention
outcomes

Conclusions and Knowledge Gaps

Primary Conclusions. The review of the literature leads to several primary conclusions, including:

• Although more effectiveness research needs to be conducted, there is strong support to indicate that
some case management approaches are effective for helping homeless people with severe mental
illness into needed services and, more importantly, into stable housing.

• ACT has the most extensive body of supportive research; results consistently indicate its
effectiveness for assisting homeless clients with severe mental illness to achieve stable housing and
to maintain needed services. There is also some but less research to indicate that ACT is effective in
a few other client outcome domains, including for reducing psychiatric symptoms.

• A very small set of studies suggest that ICM can be effective for helping clients to achieve stable
housing.

• Frequent service contact tends to be an important critical ingredient leading to positive treatment
retention and housing outcomes.

• Case management services tend to be less effective with certain clients: men, persons with more
psychotic symptoms, persons with longer homelessness histories, and people with co-occurring
substance abuse disorders.

Knowledge Gaps. While research studies have yielded important knowledge, there still remains
significant gaps in the literature and in our knowledge. These limitations and knowledge gaps include:

7-12 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Little demonstrated research knowledge about how case management services can effectively serve

homeless people who:

have substance abuse disorders

have dual diagnoses of severe mental illness and substance abuse disorders (see also Drake et al.,

in press, who concluded after a comprehensive a review of outcomes studies of integrated

treatment for all populations of dually diagnosed clients that "from a research perspective, the

status of integrated treatment for dual disorders remains that of a working hypothesis with only

modest empirical support. Given the magnitude of the problem of dual disorders, more

controlled research is needed.")

have primary health problems

are children, youths, women, or families.

have mental health disorders that do not qualify as severe mental illness

A scarcity of information about the cost-effectiveness of homeless case management services

A lack of knowledge about the most commonly used case management approaches in clinical

practice especially in areas outside of mental health.

A lack of innovations and experimentation about how case management approaches may be modified

or supplemented to create greater levels of cost-effectiveness

A lack of empirical and outcome research on consumer case management approaches.

Little research on how current or adapted case management services can effectively produce

outcomes for clients in domains other than housing and treatment retention, such as in employment,

social support, substance abuse, and recovery and wellness.

Relatively little information specifying the specific service factors or critical ingredients leading to

positive outcomes, and

Relatively little data specifying the exact nature and fidelity of case management programs.

Little research on how case management services can be combined with other intervention s-f or

example, various housing options-to improve outcomes.

Little information of the impact of case management on system problems. In appears that case

management performs the systemic "microsurgery" needed by individual clients (Hopper et al.) but

at present there is little data to assess overall system change.

Lessons Learned for Exemplary Practices: Agency Level and Practitioner
Recommendations

Criteria

A central question arises: what should be the criteria for determining exemplary case management
practices for homeless people? Clinical wisdom that emerges from the field should play a part in
determining exemplary practices. Additionally, however, consideration of empirical research, especially
as it relates to effectiveness and cost-effectiveness, should be a second important criterion. This is
especially important in the current era of accountability (Freeman & Trabin, 1994) where payers ask for
documented, hard outcomes for continued support of services. The recommendations provided below
draw upon clinical wisdom within the field, empirical research (when possible), as well as the author's
own beliefs. These recommendations are discussed within four categories: critical staff skills and
abilities, specific service principles, case management models, and organizational practices.

National Symposium on Homelessness Research 7-13

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Staff Skills and Abilities

While much more empirical research needs to be conducted, the literature does provide some impressions
and recommendations on critical factors for successful case management staff. Most of these
recommendations are related to knowledge, skills, and abilities that case managers working with
homeless clients with severe mental illness should possess. As noted elsewhere (Swayze, 1992), it is
important that case managers have a thorough knowledge of homelessness; obviously, those working in
mental health also need a thorough understanding of severe mental health disorders. Most importantly,
perhaps, workers need to be able to engage homeless clients with severe mental illness (Kline, 1993).
Engagement requires a complicated set of skills and attitudes. It includes being able to establish and
develop trusting and caring relationships, responding quickly to client need priorities, being dependable
but flexible, and being adept at covertly assessing a client's often changing needs for intensive services
or personal space (see Kline, 1993; Morse et al., 1996).

Agencies need to recruit, select, train, and supervise staff to develop skills and knowledge in the
following areas:

• Homelessness.

• The specific content area or discipline: e.g., mental health, or substance abuse, or health, or youths,
or families. Additionally, beyond their area of specialization, it is important that case managers
receive training on the needs and services for prevalent co-occurring needs, such as substance abuse
and health for mental health case managers.

• Engaging homeless clients and developing trusting relationships; this appears to be a crucial core
skill that cuts across all specialty areas.
Psychosocial assessments.
Individualized service planning.
Crisis intervention.
Suicide assessment and prevention.
Therapeutic physical management.
A comprehensive review of local services and resources.
The specific case management approach and methods.
HIV/ AIDS education and prevention.
Burnout prevention.

Training should be intensive with periodic ongoing review and the addition of specialized, needed topics.

Service Principles

Programmatic recommendations and clinical experience (e.g., Dixon et al., 1995; Francis & Goldfinger,
1986; Kline, 1993; Morse et al., 1992, 1997; Rog et al., 1987) suggests that to be maximally effective
case management services for homeless people should be guided by a core set of service principles that
include:

• Assertive and persistent outreach to meet homeless people on their own turf (as well as on their own
terms)

• Active assistance to help clients access needed resources

• Following the client's own self-directed priorities and timing for services

7-14 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

• Respecting client autonomy

• Nurturing trust and a therapeutic working alliance

• Small case loads for case management staff

Additionally, the research on service factors related to client outcomes for homeless people with severe
mental illness suggests that staff should seek to provide frequent service contact. Higher levels of
supportive services and mental health service contacts are also facilitative of better outcomes for clients
with severe mental illness. Agencies should incorporate these principles and findings into case
management programs for the homeless.

Case Management Models

Local agencies should ensure that their case management services for homeless clients are consistent
with research findings on treatment effectiveness. As noted earlier, the research strongly supports ACT
as a best practice for homeless people with severe mental illness. Some support also exists for ICM
approaches as well as Critical Time Interventions (CTT).

Organizational Practices

Organizational and system practices and policies are also important, as others have commented. In part,
organizations and systems need to empower case managers, giving them authority to access needed client
resources (Swayze, 1992). Organizations also need to provide case managers with competent and regular
clinical supervision (Rog et al., 1987). Further, it has also been observed that organizational policies can
significantly affect homeless clients and case management services (Hopper et al., 1989). In particular, it
is important for organizations and systems to provide flexible admission requirements, accommodating
clients who are mistrustful or simply unable to comply with normal admission procedures (which
sometimes routinely include requiring clients to undergo long office-based intake interviews, produce
personal identification and records, or to admit to having psychiatric problems).

It is also likely that agencies can support and foster exemplary case management services by:

• Providing thorough initial training and frequent on-going educational opportunities.

• Focusing case management interventions on specific and realistic targets. As previously stated: "If
expectations are too grand, case management will always fall short of its presumed capacity" (U.S.
DHHS, 1992, p. 8).

• Conducting QA activities that include treatment specification and implementation evaluations
(include treatment fidelity monitoring of ACT programs).

• Conducting outcome evaluations; this is important internally to assess the needs and progress of
clients served, and it will be increasingly important to funders and policy makers who are more likely
to require outcome evaluations in the future as a condition for continued funding.

• Using data to regularly engage in quality improvements

• Fostering attitudes and practices that promote further service adaptations and innovations.

• Developing, in partnership with state and local government, ongoing funding support for case
management services (instead of relying on additional demonstration grants to continue services).

National Symposium on Homelessness Research 7-15

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Promoting Exemplary Practices: Federal Level Recommendations

Given the current state of the research and knowledge base, the federal government should passionately
pursue two broad courses of action: (a) promoting the adoption of existing exemplary practices, and (b)
foster and encourage the development of new knowledge through additional research. The latter action is
as necessary as the former, given that there is still much we do not know about effective and cost-
effective case management practices for homeless people. Recommendations in each of these two areas
are presented below.

Promoting Exemplary Practices

The federal government should promote exemplary case management practices through at least three
activities: knowledge dissemination, advocacy, and financing.

Knowledge Dissemination. The federal government should promote exemplary practices through:

A wide and timely distribution of current state-of-the papers

The planning and implementation of regional or state conferences on exemplary practices
The development and distribution of relevant training materials (manuals, videos, CD-ROMS)
The development and distribution of a Best Practices for Homeless People Guidelines

Advocacy. The federal government should join forces with other groups to advocate for the wide spread
implementation of exemplary practices. One current example is for the federal government to
collaborate with NAMI on the schizophrenia PORT project, especially since the PORT treatment
recommendations call for increased ACT services.

Financing. Federal officials should seek to revise policies, regulations, and legislation as necessary to
use federal funding to promote exemplary practices. In particular, regulations and policies related to
mainstream funding programs (Medicaid, Medicare, Block Grant, PATH grant) should be reviewed and
revised to not only allow but to create incentives for the delivery of exemplary services. The growth of
managed care within the public sector (especially Medicaid and Medicare) will exert increasing influence
on the direction and extent of case management services; the federal government, both within HHS and
through consultation to states and local government, should encourage or require the funding of
exemplary practices through managed care contracts. HHS should also collaborate with HUD to
emphasize the development and funding of exemplary practices through SHP supportive services grants.
It addition to encouraging exemplary practices, the federal government should also require monitoring to
ensure that delivered services are consistent with exemplary practices (e.g., by requiring treatment
specification data, or treatment fidelity assessments). Finally, as noted elsewhere (U.S. DHHS, 1992),
the federal government supports case management services through various programs and funding
mechanisms, but "each funding source usually requires agencies to develop separate financial and service
reporting requirements. The more funding sources, the more complex, costly, and inefficient it becomes
to comply with and supply requisite information. Greater effort should be made to pursue development
of coordinated data and reporting requirements, particularly among the Federal agencies that will
increasing support and influence the scope of case management services" (pp 8-9).

7-16 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Promoting New Research

Exemplary practices for the beginning of the next millennium need to be developed from new program
development and research efforts. As noted earlier, there is a critical shortage of research knowledge in a
number of important areas. The federal government should place a priority on generating new
knowledge by supporting program development and research in the following key areas.

• Research demonstrations of case management services targeted to subgroups of homeless people
where current treatment effectiveness data is lacking. Specifically, this should include:

People with severe mental illness and co-occurring substance abuse disorders. This is a very

prevalent set of conditions and yet little current research exists about approaches that improve

substance abuse. Further, the dually diagnosed also suffer poorer outcomes in other areas (i.e.,

treatment retention, housing stability).

People with substance abuse disorders (only, or with milder mental health disorders).

Approaches that re-engineer ACT teams for this population and that integrate motivational

enhancement therapy (Miller, 1995) may be promising for development and testing.

Women with children and homeless families, especially those with non-severe mental health

disorders. Again, a re-engineering of ACT or ICM principles combined with innovative

psychotherapies may prove beneficial. Case management approaches used for children with

severe emotional disorders may also be useful for some clients (e.g., Focal Point, 1993).

People with primary health problems. ACT teams that integrate nursing specialists or nurse

practitioners (Worley et al., 1990) may be one approach to investigate.

• Research demonstrations that modify or enhance existing case management approaches in order to
improve other outcome domains for homeless people with severe mental illness. In particular,
interventions and research are needed to improve employment, social support, and, especially, long-
term recovery and wellness.

• Research demonstrations that determine the cost-effectiveness of existing case management services.

• Research demonstrations that adapt, modify, or create new case management approaches in order to
enhance cost-effectiveness.

• Research that examines the combined effectiveness of case management and other services and
resources, such as housing options.

• Descriptive research or the most common and highly regarded case management approaches in
community practice.

• Evaluation research (treatment specification and implementation evaluations) that clarifies the nature
of case management services in demonstration projects and in wide spread community practice.

• Evaluation research that identifies client characteristics and services factors affecting client outcome.

• Research that assesses the effectiveness of staff training and other dissemination efforts.

• Research that assess the impact of managed care and other significant policy changes affecting
service delivery patterns and exemplary practices.

National Symposium on Homelessness Research 7-17

wUh

■Si

Q>
CO

£ '«

O Hi

0) *

s <

c/i

C/J O

S g

3 ©

W3 J

=^ *" MM

i 8 =

< s

2 § a

60 «>

■a "S

Ml
C

£*

>>2
£-3

u <)2

o v> _: „.

x ^ « o ©* o *

<u u
1) u

3 g

u I

u E

> u

.— to

I §§

525

w
w

w
(ft

(1)

E
o

X
c
o

E
>.
co

c
o

E
o

■a H

1 i
i §

73 2

1« O 1 * n\

C oa

■a

c
u

E <-.
m2

2 U
§ Z

S<2

00
I

„g>

get

flj

«C

j*^

<*£

§>-2

.§

«j

H»

.4>

■■*

•5 E U x>

'I 1
I |

a o

W kJ

iS
o

e
8 %

'El

t» Q

u
1.1°

5 B0

S §

1 J

I 6

£ 2

H 3

Q V3

u «

2 2

03 S

x:
<j

(0
CD

E
o

I
c
o

co
o

c
o

.9*
'H

u as
<u p «

a. b v

V5 U b

<u ©
u .S

-Si

1-8
I*

ft. -O

•• £
,0 w

S> »
£ *

5 £
Q) a.

t ">

o c

« .2

■S Vlfi

u •-

■a

52> 3 §

< -8 a a

•s

c
o

2 'S

a >
2 -s

4) C

3 1

2 dS

sid

S o> — —
c On

o -*

ll-a

u JJ

I a

O C

g a

I §

§s

U o

■c ^

X> — 1

C ON

C U On

».

■a

■s

"5 "8

■s

c
u

1/1

- a

n- ■-

O T3

2*1

i> J=

5 «n

§ -o

8 §

I-

•0 &

a 3

■g

£ 8

> o

■a

■o

co
w

o
c
w
«

E
o

c
o

E
3
"35
o

c
o

T3
5

O <S

33 O

■a

o
00

«> SI

fl) c
O o

S> '■&
&£

C TO
CQ .O

o
"I

u
©

Cfl

J3
u
a

« S

3 S

■2 *>

H g

1
§

a
c

• PB

•a

3 v

•c

a SI

c <«
o a>

u a

a
s

a
u

4>
U

•s

•c
a.

o
E

oo
oo

£
o

.us
oo

f— I

L-

<On

c
a

c
o

E
u

C3
60

C
u ^

•^*

1—

2 E

c
a
o

o
u

C/5

■>*

•a

■*

y— V

*-w

t/5

|c«

3
OO

3 ^

3
O

-a
u
o

3
•O

■ta-»

1-^

03
C
03

*e3

O
fa

O. ^

oo ^

O «

* ff

i— i
2

SMI

(State
disch:

H
U

o
E

i— i

•^N

oo
3

oo
O

i— >

§ ^

Lehm
(1997

t OV

u 0\ ON

o o\

O ON ON

M C^

S CC

$»

Q. 1

&•

'■C

H»

•5

-S V

1/5 O

4=
top

-a
o

2
c/T

E
2

1
C

1—
CO

•^

-o

'co

t/3

Ud
22

•4— »

'to

c
o

c
4>

3
O

•-3

E
s
"8

H
O
<

'■*— »
3

-o

<u
o

3
T3
O
l-

o
u

H
U

c/i
U

■*— >

£
>*

H
U

•o

s I

O (V

U Q

c/j

3:3

<C .t« in

• S £

eo 3 •*

> 62

H gffl

^ S CO

S Poo

i- ON On

O Os ON

% CO

r-4

8 > "2
•§■8-8

y cu Pi oo

1
O

K
i— i

-o

V-

ON
ON

y-*

!^S

—

-o

■a

U-l

c
2

H
U

< O

co"

cfc

-o

.E -3

a>
QC
w

<0
(0

E
o

c
o

'55

o
a.

c
o

NO
ON

U
o

E
H

■a g
.a e:

u £

'>
c 73

D
E
o

52 On

oo C

CM
CM

|
1

o
S3

<
e
E

WD
03
S
03

e
s

•a

pff ©

3 ' c

c« a.

o
3

r ««
o v

U Q

■w D

e 9

.- °

<u <u

•3 S

£^ 2;

"* ..

u u

w S3

3 2

2 2

* s

in vo

^ is

2 8

v ?

Jg £

O H

«5
. i

o ^t

3 I

I I

o o

DC £

N©
ON
ON

o <u

§> E

to £

# s

5 $

4>
>

£ o

2 "O
o <u

_ Q.

\s o

§ Q

I
o

0\ 4)

« s

6. >
p t>
-3 «°

T3 O

>- -s

c
o

5 p

— < T3 r-

c * -a

U - •»-

S fg «

- E Xl >>

a*'

,i$ « o

v©

c/5 "2

4>
00

S3
j=
o

t/5

•3
u

S3
o

W5 y~*

S3 #

o oo

3 tfl

tV3 >

£ K

<L>

«3

■a

S u

• — v>
X> 3

1/5 o

00 «
C C

2 B

M 00

T3
3

■3

° §

"O >

■§!

l-s-3

■a -i

1 ^.

'81

to S

Cm i-h

(Z) w

t/1 -2

= 2

C/5

<U "O

C/3

"u >.

** J4

MI:

tris

&0 «

On
ON

« -s

i «

C (J

« ■6' «

P •-

3
00

E 1 a

o u

O J>

■3 >> O

3 X) S

III

g 00 §

o .g i-

fc M o

i - o ©

t3 oo

o cj

is H

4) > <0

-o

1/5 "O

en u

4> co

E oo

O S3

DC '•&

PL,

4) ON

•2

Q. "<

■G

v.
5

•hi

'■i

a
E

pff ®
P ' E

■S «
C/i ft.

•s

3. C J
a -s

U Q

■w S

e s

<u ©

— «-

03 V
O

1 1-8

u Q. ■-

£ M M

3- C C

4) -3 -3

^ o o

U j: j:

e i
1 1

<U D.
O S

2 «
& o

B U
— C

8 .9

§ 1

■- -S

3 eg
O* c

W o

— 60 .-.
3 a l -
c S

1)3.

6 S <g

.3 oo <G
5 d cd

& U &

>< o S

«> c a

CO 4) &o
3 5 3

cs u

S
o

X5
3
00

GO
o

2
o

•8

« <u o

u B **

S S a to

1 ■§ i p

3
O

3 1

O 4>

■a I

<U CM

U o

PS o

a o

-E
60
3
O

•3

ft) TO

a °

B o

I -s

1 a

0) — .3

S 3 3

GO

GO O

oj -

oo -< O X oo <

- B 2

e js 3

O 3 X)

x -" !

a°S

§y

J .9

B "O
— CJ
60

cd
60
B
U

u
o

B B

bH 3

o o

(/J ^

■b e

2 *3

oo ^
vo O

VO '^
00 <u

B «-

'53 i>

3
O
X!

.■a so

"3 .£

3 <D
CT X)

S g
o >

.3 I-
4)

a b

B «
4> 60

o §

B- S

a* °

XS - ,4)

y o

g s

.- O
J> X!

'p.

•3 oo
60 g

> a

35 IB

e^-

c>-

»-H

•o

'3
CO

»— i

>ri

i— i

U D

o
X

<0 ^H

oj 0\

2 c

1
i

•c

V
'I

1
I

o
■o

u
•o

o
a.
u

CO
CD
CO

CO
CO

E
o

c
o

3
CO

o
a.

>»

t/>

c
o

•c

1?^

■£•

p»

■8

«k

(0 *M

H»

.Q>

•^

■a

pff ©
■6 4>

o
U

■w a

C 9

V ©

— «s

U O

'c
o

C/5

c
o

."2

I—

t/5

-o

C/3

'«a

c
p— i

S3 O

s *

cm C

S3
S

o
u

< CL,

| B
DC c/3

C On

co
d)

0)
©

0)
(0

<j>

E
o

X
c
o

«
o

E
to

c
o

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Table 4

Service and Client Factors Related to Case Management Outcomes

Service Factors (Mediators)

Study

Outcome Variable

Service Factor (Mediator)

Studv Design

Morse etal. (1994)

Stable housing

Supportive Services

Experimental/

Housing Service Contracts

Multivariate

Entitlement Service Contracts

Analysis

MH Service contacts

Client satisfaction

Supportive services

MH services

Overall service contacts

Dixon etal. (1994)

Receipt of Section

Representative Payee services

Experimental/

8 certificate

(negative relationship)

Bivariate
Categorical

Barrow et al.

Retention in CM services

Staff client interaction

Pre-post/

Stable housing

Continuing CM services

categorical

Herinckx et al.

Length of retention

ACT services

Experimental/

In treatment

Multivariate

7-26

National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Client Characteristics (Moderators)

Study

Outcome Variable

Service Factor (Mediator)

Study Design

Dixon etal. (1994)

Receipt of Section 8

Schizophrenia (negative

Experimental/

certificate

relationship)

Psychotic symptoms (negative

relationship)

Bivariate

Barrow etal. (1996)

Retention in CM
services

Psychotic symptoms (negative)

Morse etal. (1994)

Stable housing

Women (positive)

Experimental/

Caucasian (Positive)

Mulitvariate

Rife et al.

Retention in CM
services

Frequency of CM contact

Pre-post/ Multivariate

Herinckx (1997)

Length of retention

Number of nights homeless

Experimental/

in treatment

(negative relationship)

multivariate
analysis

Hurlburt et al.

Housing stability

Gender (female)

Experimental/

(1996)

Time homeless (negative relationship)

multivariate

Alcohol problems (negative)

analysis

Drug problems (negative)

Rife etal. (1991)

Retention in CM

Independent living skills

Pre-post/ Multivariate

services and in

Age

Analysis

housing

Substance abuse (negative)
Times homeless (negative)
Number of hospitalizations (negative)

National Symposium on Homelessness Research

7-27

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

References

Bachrach, L.L. (1992). Case Management Revisited. Hospital and Community Psychiatry, 43(3): 209-
210.

Ball, F. J., & Havassy, B. E. (1984). A Survey of the Problems and Needs of Homeless Consumers of
Acute Psychiatric Services. Hospital & Community Psychiatry, 35, 917-921.

Barrow, S., Cordva, P. & Struening, E. L. (1996). Evaluation ofA-Plus: A Report on Case Management
Services and Housing Outcomes. New York, NY: New York State Psychiatric Institute.

Bassuk, E. L. (1991). Kidstart: Developing a Model Program. In R.W. Carman (Ed.), Homeless
Children in the Kidstart Program: Three Portraits. Newton Centre, MA: The Better Homes Foundation.

Bebout, R .R. (1993). Contextual Case Management: Restructuring the Social Support Networks of
Seriously Mentally 111 Adults. In M. Harris & H. C. Bergman (Eds.) Case Management for Mentally III
Patients: Theory and Practice. New York, NY: Harwood Academic Publishers.

Blankertz, L. & White, K. (1990). Implementation of a Rehabilitation Program for Dually Diagnosed
Homeless. Alcoholism Treatment Quarterly, 7(1): 149-163.

Blankertz, L. E. & Cnaan, R. A. (1994). Assessing the Impact of Two Residential Programs for Dually
Diagnosed Homeless Individuals. Social Service Review, 68: 536-560.

Bonham, G. S., Hague, D. E., Abel, M. H., Cummings, P. & Deutsch, R. S. (1990). Louisville's Project
Connect for the Homeless Alcohol and Drug Abuser. Alcoholism Treatment Quarterly, 7(1): 57-78.

Borgford-Parnell, D., Hope, K. R., Deisher, R. W. (1994). A Homeless Teen Pregnancy Project: An
Intensive Team Case Management Model. American Journal of Public Health, 84(6): 1029-1030.

Brekke, J. S. (1988). What Do We Really Know about Community Support Programs? Strategies for
Better Monitoring. Hospital and Community Psychiatry, 39(9): 946-952.

Brindis, C, Pfeffer, R., Wolfe A. (1995). A Case Management Program for Chemically Dependent
Clients with Multiple Needs. Journal of Case Management 4(1): 22-28.

Brindis, C, Pfeffer, R., Wolfe, A. (1995). A Case Management Program for Chemically Dependent
Clients with Multiple Needs. Journal of Case Management 4 (1): 22-28.

Burns, B. J. & Santos, A. B. (1995). Assertive Community Treatment: An Update of Randomized
Trials. Psychiatric Services 46(1): 669-675.

Campbell, D. T., & Cook, D. (1979). Quasi-Experimentation Design and Analysis: Use for Field
Settings. Chicago: McNally.

Carman, R. W. (1991). Homeless Children in the Kidstart Program: Three Portraits. Newton Centre,
MA: The Better Homes Foundation.

7-28 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Deci, P. A., Santos, A. B., Hiott, D. W., Schoenwald, S., Dias, J. K. (1995). Dissemination of Assertive
Community Treatment Programs. Psychiatric Services 46(1): 676-678.

Dennis, D. L., Buckner, J. C, Lipton, F. R., Levine, I. S. (1991). A Decade of Research and Services for
Homeless Mentally 111 Persons: Where Do We Stand? American Psychologist, 46: 1 129-1 138.

Dixon, L., Friedman, N., & Lehman, A. (1993). Housing Patterns of Homeless Mentally 111 Persons
Receiving Assertive Treatment Services. Hospital and Community Psychiatry 44(3): 286-389.

Dixon, L., Krauss, N. & Lehman, A. (1994). Consumers as Service Providers: The Promise and
Challenge. Community Mental Health Journal 30(6): 615-634.

Dixon, L., Krauss, N., Kerman, E., Lehman, A. F. & DeForge, B. R. (1995). Modifying the PACT
Model for Homeless Persons with Severe Mental Illness. Psychiatric Services 46(1): 684-688.

Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G. B., Xie, H., Miles, K., Ackerson, T. H. (1998).
Assertive Community Treatment for Patients with Co-Occurring Severe Mental Illness and Substance
Use Disorder: A Clinical Trial. American Journal of Orthopsychiatry 68(2): 201-215.

Drake, R. E., Mercer-McFadden, C, Mueser, K. T., McHugo, G. J., & Bond, G. R. A Review of
Integrated Mental Health and Substance Abuse Treatment for Patients with Dual Disorders.
Schizophrenia Bulletin. In Press

Durell, J., Lechtenberg, B., Corse, S:, Frances, R. J. (1993). Intensive Case Management of Persons
With Chronic Mental Illness Who Abuse Substances. Hospital and Community Psychiatry 44(5): 415-
416, 428.

First, R. J., Rife, J. C. & Kraus, S. (1990). Case Management with People Who are Homeless and
Mentally 111: Preliminary Findings from an NIMH Demonstration Project. Psychosocial Rehabilitation
Journal 13(A): 87 -91.

Focal Point. (1993). Case Management for Families and Children. Focal Point, 7(1): Winter/Spring.
Research and Training Center, Regional Institute for Human Services, Portland State University.

Frances, A. & Goldfinger, S. (1986). Treating' a Homeless Mentally HI Patient Who Cannot Be
Managed in the Shelter System. Hospital and Community Psychiatry 37(6): 577-579.

Freddolino, P. P. & Moxley, D. P. (1992). Clinical Care Update: Refining and Advocacy Model for
Homeless People Coping with Psychiatric Disabilities. Community Mental Health Journal 28(4): 337-
352.

National Symposium on Homelessness Research 7-29

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Freeman, M. A., & Trabin, T. (1994). Managed Behavioral Healthcare: History, Models, Key Issues,
and Future Course. Washington, DC: Superintendent of Documents, U. S. Government Printing Office.

Goldfinger, S. & Chafetz, L. (1984). Developing a Better Service Delivery System for the Homeless
Mentally 111. In Lamb, H.R. (ed.). The Homeless Mentally III: A Task Force Report. Washington, DC:
American Psychiatric Press.

Hamptom, B., Koor, W., Bond, G., Mayes, J, & Havis, P. (1992). Integration Service System Approach
to Avert Homelessness: CSP Homeless Prevention Project for HMI Adults. Unpublished manuscript,
State of Illinois, Chicago, IL.

Herinckx, H. A., Kinney, R. F., Clarke, G. N., Paulson, R. I. (1997). Assertive Community Treatment
Versus Usual Care in Engaging and Retaining Clients with Severe Mental Illness. Psychiatric Services
48(10): 1297-1306.

Hopper, K., Mauch, D. & Morse, G. (1989). The 1986-1987 NIMH- Funded CSP Demonstration
Projects to Serve Homeless Mentally III Persons: A Preliminary Assessment. Rockville, MD: National
Institute of Mental Health.

Hurlburt, M. S., Hough, R. L., Wood, P.A. (1996). Effects of Substance Abuse on Housing Stability of
Homeless Mentally 111 Persons in a Supported Housing Program. Psychiatric Services 47(1): 731-736.

Jansen, A., Masterton, T., Norwood, L., Viventi, M. (1992). Harbinger Team rV: Assertive Community
Treatment for People with the Dual Diagnosis of Mental Illness and Substance Abuse. Innovations &
Research 1(2): 11-17.

Jerrell, J. M., Ridgely, M. S. (1995). Comparative Effectiveness for Three Approaches to Serving
People with Severe Mental Illness and Substance Abuse Disorders. The Journal of Nervous and Mental
Disease 183(9): 566-576.

Johnsen, M., Samberg, L., Calsyn, R., Blasinsky, M., Landow, W., & Goldman, H. (1998). Case
Management Models for Persons who are Homeless and Mentally 111: The Access Demonstration Project.
Unpublished Paper.

Joint Commission on Accreditation of Hospitals. (1979). Principles for Accreditation of Community
Mental Health Service Programs. Chicago Author.

Kline, J. D. (1993). Challenges to the Clinical Case Management of the Chronic Mentally 111: Emerging
Special Populations. In M. Harris & H. C. Bergman, Case Management for Mentally III Patients, Theory
and Practice. US: Harwood.

Kline, J., Harris, M., Bebout, R., Drake, R. E. (1991). Contrasting Integrated and Linkage Models of
Treatment for Homeless, Dually Diagnosed Adults. In K. Minkoff & R. E. Drake (Eds.), Dual Diagnosis
of Major Mental Illness and Substance Disorders. New Directions for Mental Health Services 50: 95-
107. San Francisco, CA: Jossey-Bass.

7-30 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Korr, W. S., & Joseph, A. (1991). Housing the Homeless Mentally 111: Findings from Chicago. Journal
of Social Service Research 27(1): 53-68

Kuczenski, J. (1992). Families. In The Health Care for the Homeless Project in Ramsey County St.
Paul, MN West Side Community Health Center.

Lehman A. F., Dixon, L. B., Kernan, E., DeForge, B. R. & Postrado, L. T. (1997). A Randomized Trial
of Assertive Community Treatment for Homeless Persons With Severe Mental Illness. Archives of
General Psychiatry 54: 1038-1043.

Levine, I. & Fleming, M. (1986). Human Resource Development: Issues in Case Management.
Rockville, MD: National Institute of Mental Health, May.

McCarty, D., Argeriou, M., Krakow, M., & Mulvey, K. (1990). Stabilization Services for Homeless
Alcoholics and Drug Addicts. Alcoholism Treatment Quarterly 7(1): 31-45.

McGrew, J. H. & Bond, G. R. (1995). Critical Ingredients of Assertive Community Treatment:
Judgments of the Experts. Journal of Mental Health Administration 22(2): 1 13-125.

McGrew, J. H., Bond, G. R. Dietzen, L., & Salyers, M. (1994). Measuring the Fidelity of
Implementation of a Mental Health Program Model. Journal of Consulting and Clinical Psychology
62(4).

Mechanic, D. (1991). Strategies for Integrating Public Mental Health Services. Hospital and
Community Psychiatry 42(8) : 797-80 1

Meisler, N., Blankertz, L., Santos, A. B., McKay, C. (1997). Impact of Assertive Community Treatment
on Homeless Persons with Co-occurring Severe Psychiatric and Substance Use Disorders. Community
Mental Health Journal 33(2): 1 13-122.

Mercer, C. C, Mueser. K. T., & Drake, R. E. (1998). Organizational Guidelines for Dual Disorders
Programs. Psychiatry Quarterly 69: 145-168.

Mercier, C. & Racine, G. (1991). A Process Study of Case Management with Homeless Women. Paper
presented at the American Evaluation Association Annual Meeting, Chicago, IL (Presentation: 16 pages)

Miller, W. R. (1995). Increasing Motivation for Change. In R. K. Hester & W. R. Miller (Ed.).
Handbook of Alcoholism Treatment Approaches: Effective Alternatives.

Minkoff, K. & Drake, R. E. (Eds.) (1991). Dual Diagnosis of Major Mental Illness and Substance
Disorder. New Directions for Mental Health Services 50: 95-107. San Francisco: Jossey-Bass.

Morse, G. (1992). Causes of Homelessness. In M. Robertson & M. Greenblatt, (Eds.). Homelessness:
A National Perspective. New York: Plenum.

Morse, G. A. & Calsyn, R. J. (1986). The St. Louis Mentally Disturbed Homeless: Needy, Willing, But
Underserved. International Journal of Mental Health 14: 74-94.

Morse, G. A., Calsyn, R. J., Allen, G., Kenny, D. A. (1994). Helping Homeless Mentally 111 People:

National Symposium on Homelessness Research 7-31

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

What Variables Mediate and Moderate Program Effects? American Journal of Community Psychology,
22(5): 661-683.

Morse, G. A., Calsyn, R. J., Klinkenberg, W. D., Trusty, M. L., Gerber, F., Smith, R., Tempelhoff, B.,
Ahmad, L.( 1997). An Experimental Comparison of Three Types of Case Management for Homeless
Mentally 111 Persons. Psychiatric Services, 48(4): 497-503.

Mueser, K. T., Bond, G. R., Drake, R. E., Resnick, S. G. (1998) Models of Community Care for Severe
Mental Illness: A Review of Research on Case Management. Schizophrenia Bulletin 24(1): 37-47.

Oakley, D. A., Dennis, D. L. (1996). Responding to the Needs of Homeless People with Alcohol, Drug,
and/or Mental Disorders. In J. Baumohl (Ed). Homelessness in America. Phoenix, AZ: Oryx Press, 179-
186,

Orwin, R. G., Sonneffeld, L. J., Garison-Mogren, R., Smith, N. G. (1994). Pitfalls in Evaluating the
Effectiveness of Case Management Programs for Homeless Persons. Evaluation Review, 18(2): 153-207.

Osher, F. C, Kofoed, L. L. (1989). Treatment of Patients With Psychiatric and Psychoactive Substance
Abuse Disorders. Hospital and Community Psychiatry 40(10): 1025-1030.

Raif, N. R. & Shore, B. K. (1993). Advanced Case Management: New Strategies for the Nineties.
Newbury Park; CA: Sage Publications, Inc.

Rapp, C. A. (1993). Theory Principles, and Methods of the Strengths Model of Case Management. In
M. Harris & H. C. Bergman, Case Management for Mentally III Patients, Theory and Practice. US:
Harwood.

Rife, J. C, First, R. J., Greenlee, R. W., Miller, L. D., et al. (1991). Case Management with Homeless
Mentally 111 People. Health and Social Work 16(1): 58-67.

Rog, D. J. (1988). Engaging Homeless Persons with Mental Illness into Treatment. Alexandria, VA:
National Mental Health Association.

Rog, D. J., Holupka, C. S., McCombs-Thirnton, K. L., Brito, M. C, Hambrick, R. (1996) Case
Management in Practice: Lessons from the Evaluation of the RWJ/HUD Homeless Families Program.
Journal of Prevention and Intervention in the Community 15(2): 67-82

Rog, D., Andranovich, G., & Rosenblum, S. (1987) Intensive Case Management for Persons Who are
Homeless and Mentally III: A Review ofCSP and Human Resource Development Program Efforts, Vol.
1-3. Rockville, MD: National Institute of Mental Health.

7-32 National Symposium on Homelessness Research

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Roth, L. & Fox, E. R. (1990). Children of Homeless Families: Health Status and Access to Health Care.
Journal of Community Health, 75(4): 275-284, August.

Savarese, M., Detrano, T., Koproski, J., & Weber, CM. (1990). Case Management. In Brickner, P.W.,
Scharer, L.K., Conanan, B.A., Savarese, M., & Scanlan, B.C. (Eds), Under the Safety Net: The Health
and Social Welfare of the Homelessness in the United States. New York, NY: W.W. Norton &
Company.

Shern, D. L., Tsemberis, S., Anthony, W., Lovell, A. M., Richmond, L., Felton, H. C, Winarski, J., &
Cohen, M. (1996). Serving Street Dwelling Individuals with Psychiatric Disabilities: Outcomes of a
Psychiatric Rehabilitation Clinical Trial. Unpublished manuscript, Florida Mental Health Institute,
University of South Florida, Tampa, FL.

Solomon, P., & Draine, J. (1995a). One- Year Outcomes of a Randomized Trial of Case Management
with Seriously Mentally 111 Clients Leaving Jail. Evaluation Review, 19: 256-273.

Solomon, P., & Draine, J. (1995b). The Efficacy of a Consumer Case Management Team: 2- Year
Outcomes of a Randomized Trial. Journal of Mental Health Administration, 22: 135-146.

Stein, L.I. (1992). On the Abolishment of the Case Manager. Health Affairs 11(3): 172-177.

Stein, L. I. & Test, M. A. (1985). The Training in Community Living Model: A Decade of Experience.
Jossey-Bass Inc., San Francisco, CA: New Directions for Mental Health Services No. 26.

Stephens, D., Dennis, E., Toomey, M., & Holloway, J. (1991). The Diversity of Case Management
Needs for the Care of Homeless Persons. Public Health Reports 106(1): 15-19.

Steward, D. (1992). Case Management. In the Health Care for the Homeless Project in Ramsey County
St. Paul, MN: West Side Community Health Center.

Surles, R. W., Blanch, A. K., Shern, D. L. & Donahue, S. A. (1992). Case Management as a Strategy for
Systems Change. Health Affairs 151-163.

Swayze, F. V. (1992). Clinical Case Management with the Homeless Mentally 111. In Lamb, H. R.,
Bachrach, L.L. & Kass, F.I.(Eds.), Treating the Homeless Mentally III. Washington, DC: American
Psychiatric Association.

Teague, T. B., Bond G. R., Drake, R. E. (1998). Program Fidelity in Assertive Community Treatment:
Development and Use of a Measure. American Journal of Orthopsychiatry 68(2): 216-232.

U. S. Department of Health and Human Services. (1992). Case Management for Special Populations.
Washington, DC: HHS, Bureau of Primary Health Care.

Wasylenki, D. A., Goering, P. N., Lemire, D., Lindsey, S. & Lancee, W. (1993). The Hostel Outreach
Program: Assertive Case Management for Homeless Mentally 111 Persons. Hospital and Community

National Symposium on Homelessness Research 7-33

A Review of Case Management for People that are Homeless:
Implications for Practice, Policy and Research

Psychiatry 44(9): 848-853.

Willenbring, M. L., Ridgely, M. S., Stinchfield, R., & Rose, M. (1991). Application of Case
Management in Alcohol and Drug Dependence: Matching Techniques and Populations. Rockville, MD:
National Institute on Alcohol Abuse and Alcoholism.

Willenbring, M. L., Whelan, J. A., Dahlquist, J. S., & O'Neal, M. E. (1990). Community Treatment of
the Chronic Public Inebriate I: Implementation. Alcoholism Treatment Quarterly 7(1): 79-97.

Wolff, N, Helminiak, T. W., Morse, G. A., Calsyn, R. J., Klinkenberg, W. D„ & Trusty, M. L. (1997).
Cost-Effectiveness Evaluation of Three Approaches to Case Management for Homeless Mentally 111
Clients. American Journal of Psychiatry, 154: 341-348.

Worley, N. K., Drago, L. & Hadley, T. (1990). Improving the Physical Health-Mental Health Interface
for the Chronically Mentally 111: Could Nurse Case Managers Make a Difference? Archives of
Psychiatric Nursing 4(2): 108-1 13.

Yates, G., Pennbridge, J., Swofford, A., MacKenzie, R. (1991). The Los Angeles System of Care for
Runaway/Homeless Youth. Journal of Adolescent Health 12: 555-560.

Young, N. K., Grella, C. E. (1998). Mental Health and Substance Abuse Treatment Services for Dually
diagnosed Clients: Results of a Statewide Survey of County Administrators. The Journal of Behavioral
Health Services and Research 25(1): 83-92.

7-34 National Symposium on Homelessness Research

Balancing Act: Clinical Practices
That Respond to the Needs of Homeless People

Marsha McMurray-Avila, M.C.R.P.

Lillian Gelberg, M.D., M.S.P.H.

William R. Breakey, M.D.

Abstract

This paper describes special adaptations to clinical practice necessary for addressing the most common
health problems of homeless individuals and families. A case is made for the integration of primary care,
mental health and substance abuse services as the preferred approach to care for this population, based on
the complexity of multiple interrelated health problems that are seen. These problems are examined in a
section on the epidemiology of health problems common to people without homes. Homeless people
face numerous barriers to access which can be overcome by adaptations to the structure of the delivery
system, including extensive outreach, mobile sites and flexibility in policies and procedures. The nature
of the homeless condition also calls for special adaptations to clinical practice in the areas of intake and
assessment, clinical preventive services, diagnosis, follow-up to assure continuity of care, referrals to
specialty care and linkages to other services. Specific adaptations for treatment of physical and mental
illnesses are presented, with discussion of primary care, treatment services for substance use disorders,
treatment services for serious and persistent mental illnesses, and special services for homeless people
with dual diagnoses. The paper concludes with comments on how to address the threats that challenge
successful continuation of the unique approach to homeless health care that has evolved, including:
inadequate funding to fully implement the integrated approach to homeless health care; impact of market-
driven managed care; lack of funding for accessible and appropriate substance abuse treatment; limited
cost and outcome data; the disconnect between research and practice; and the scarcity of skilled
practitioners willing to serve this population, increased demand for services, decreased capacity and
limited resources, the effects of Medicaid managed care, and the need for more qualified practitioners in
this field.

Lessons for Practitioners, Policy Makers, and Researchers

After more than a decade of practice, there is considerable agreement as to what constitutes state of the
art clinical services for homeless people. Based on research demonstration programs sponsored by
public and private funding sources, and experience accumulated by front line workers in the many health
care programs across the country, nine general principles have emerged as lessons for practitioners
involved in providing care for homeless people:

• The importance of outreach to engage clients in treatment.

• Respect for the individuality of each person.

• Cultivation of trust and rapport between service provider and client.

• Flexibility in service provision, including location and hours of service, as well as flexibility in
treatment approaches.

National Symposium on Homelessness Research 8-1

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

The need to attend to the basic survival needs of homeless people and to recognize that until those

needs are met, health care may not be an individual's priority.

The importance of integrated service provision and case management to coordinate the needed

services.

Clinical expertise to address complex clinical problems, including access to specialized care.

Need for a range of housing options, including programs combining housing with services.

A longitudinal perspective that ensures continuing care until the person's life situation is stabilized.

8-2 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Introduction

Physical and mental illnesses are implicated as both causes and consequences of homelessness for many
individuals. While the shortage of safe, decent, and affordable housing is the most fundamental cause of
homelessness, untreated physical and/or mental health problems create vulnerabilities that can lead to
loss of income and home. At the same time, those who experience homelessness are subject to
conditions that can result in deterioration of health or exacerbate existing chronic or acute illnesses,
leading to rates of illness and injury from two to six times higher than for people who are housed
(Wright, 1990). Homelessness also severely complicates the delivery of health services (Institute of
Medicine, 1988). Without access to appropriate health care, acute and chronic health problems may go
untreated, creating medical complications in multiple co-occurring conditions and ultimately impeding
the individual's ability to overcome homelessness. Failing to provide homeless people with health care
of a standard that is available to other people, even when they need elaborate or expensive treatments,
constitutes a form of discrimination that should be unacceptable in a democratic society (Bangsberg et
al., 1997).

A strong commitment by homeless health care practitioners to respond directly to these complex multiple
health care needs of homeless people has resulted in the evolution of an integrated approach to providing
clinical services. Primary health care, mental health services and substance abuse treatment need to be
made available either from one organization's comprehensive service system, or if this is not feasible,
through linkages with other agencies.

The purpose of this paper is to describe current clinical practice within an integrated system of primary
care, mental health and substance abuse services for people without homes. Whenever possible, research
has been used to support the discussion. A significant amount of research is available to describe the
health problems of homeless people. However, less is found in the research literature related to efficacy
of specific clinical practices with this population. Experience in the field and descriptive accounts by
practitioners are the basis for many of the special adaptations to clinical practices recommended here for
addressing the most common health problems of homeless individuals and families. The discussion is
presented in the following sections:

• Outcomes: What do we want our clinical interventions to accomplish?

• Epidemiology: What are the health problems of homeless people?

• System adaptations designed to overcome access barriers.

• Adapting clinical practices to the homeless condition.

• Specific adaptations for treatment of physical and mental illnesses (descriptions of treatment
approaches within each of the three specific areas of interest: primary health care, substance abuse
treatment and mental health services, with special consideration for dealing with people who are
dually diagnosed).

Outcomes: What Do We Want Our Clinical Interventions To Accomplish?

Although there is a major movement to quantify actual outcomes of health care interventions, providers
of health care to homeless people have had to adapt their own notions of successful outcome to the
realities of the homeless existence. A working group on homeless health outcomes was convened in
1996 by the Health Care for the Homeless (HCH) Branch of the Division of Special Populations/Bureau
of Primary Health Care (U.S. Department of Health and Human Services, 1996). This group identified

National Symposium on Homelessness Research 8-3

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

seven systems-level outcomes and seven client-level outcomes that are goals for federally-funded HCH
projects. The seven system-level outcomes are interrelated in that HCH projects "provide access for
homeless people to a range of comprehensive services. They offer continuity of care within an
integrated system to help contain costs and prevent new or recurring problems. Ideally, client
involvement is evident in every step of this process." The seven client-level outcomes are related, but
can be measured independently of one another. These include: improved health status; improved level
of functioning; improved quality of life; involvement in treatment; disease self-management; client
choice; and client satisfaction.

However, the group also noted that "because homeless people are a heterogeneous group with multiple
and complex needs, numerous personal and societal factors outside the clinicians' control may impact the
final outcomes for individual patients. Also, their mobility often makes it difficult to track homeless
people for follow-up measures" (U.S. Department of Health and Human Services, 1996, p.ii).

A central question in this discussion is determining what qualifies as a "successful outcome". Health
care practitioners working with homeless people are concerned with improving health status, level of
functioning and quality of life. Obviously, the most significant change affecting all of these would be
acquiring permanent housing. Although this is certainly a recommended goal for health programs,
usually undertaken within the framework of case management services, it is not an outcome that can be
used to measure the effectiveness of clinical care. This is particularly true given the lack of resources for
appropriate affordable housing in most communities, over which the health care practitioner has little
control.

The nature of homelessness and the health conditions that accompany it also complicate the
determination of "successful outcome." Homeless people, particularly those with addictions and/or
mental illness, go through various stages of change as they move towards the desirable improvements in
health status, functioning and quality of life. These stages include: precontemplation; contemplation;
action; maintenance; and relapse (Prochaska, DiClemente & Norcross, 1992). This is not a linear process
and each individual changes at his or her own rate. Chronic conditions — especially substance abuse and
mental illness — are subject to regressions and relapse. This should be expected and needs to be built into
program planning, as well as into outcome evaluation methodologies. For example, while recognizing
that the incremental steps may occur at different points and may sometimes go backwards, a "hierarchy
of objectives" can be constructed for homeless people who are mentally ill, beginning with the most
basic to the most sophisticated as follows (Breakey, Susser & Timms, 1992):

Accepts sandwich from outreach worker

Maintains eye contact with outreach worker

Accepts clean clothing

Accepts housing/shelter assistance

Permits interview with clinician

Accepts medication

Spontaneously attends to personal hygiene

If dangerous, is brought to emergency facility

Attends clinic regularly

Manifests reduction in symptoms

Improvement in self-care ability

Adjusts satisfactorily to sheltered living program

Participates in social activities

8-4 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Maintains mutually satisfactory relationship
Transfers from homeless program to generic program
Participates in vocational rehabilitation program
Able to live independently
Sustains competitive employment

Homeless health care practitioners are often limited to measuring change in small increments such as
these. New strategies to assess these incremental outcomes are needed, such as the Service Continuum
matrix being developed by the HCH Network, a program of the Seattle/King County Department of
Public Health, to track clients in their progress towards stability and independence. This assessment
matrix is based on incremental change in the areas of relationship, financial resources, health/treatment,
social support network and residential status in stages ranging from the initial approach through
companionship, partnership and mutuality to stability and independence (HCH Network, 1998).

Other significant work has been initiated to develop appropriate outcome measurements for the homeless
health care setting. As a follow-up to the working group on homeless health care outcomes mentioned
above, 20 HCH projects were provided federal funding to develop outcomes studies in a variety of areas.
It is hoped that the study results and lessons learned will encourage further work in this area by homeless
health care projects (U.S. Department of Health and Human Services, 1998b).

Epidemiology: What Are the Health Problems of Homeless People?

As a consequence of the poor nutrition, lack of adequate hygiene, exposure to violence and to the
elements, increased contact with communicable diseases, and fatigue that accompany the conditions of
homelessness, people without homes suffer from ill health at much higher rates than people living in
stable housing. Several studies have found that one-third to one-half of homeless adults have some form
of physical illness (Bassuk & Rosenberg ,1988; Burt, 1989; Gelberg & Linn, 1989; Morse & Calsyn,
1986; Roth & Bean, 1986). At least half of homeless children have a physical illness (Wood et al., 1990)
and they are twice as likely as housed children to have such illnesses (Wright & Weber, 1987). This lack
of health takes its toll by preventing many homeless people from exiting homelessness. For example,
one-quarter of homeless adults reported that their poor health prevented them from working or going to
school (Robertson & Cousineau, 1986). Even more seriously, rates of mortality are three to four times
higher in the homeless population than they are in the general population (Alstrom, Lindelius & Salum,
1975; Hanzlick & Parrish, 1993; Hibbs et al., 1994; Morbidity and Mortality Weekly Report, 1991 and
1992; Wright & Weber, 1987).

The most common physical illnesses among homeless persons include upper respiratory tract infections,
trauma, female genitourinary problems, hypertension, skin and ear disorders, gastrointestinal diseases,
peripheral vascular disease, musculoskeletal problems, dental problems, and vision problems (Wright &
Weber, 1987; Reuler et al., 1986; Miller & Lin, 1988; Wood et al., 1990). Inadequate immunization,
while not a physical illness, reflects the lack of preventive health care in this population (Alperstein et
al., 1988; Wood et al., 1990; Miller & Lin, 1988). However, the two health conditions most likely to trap
people in a state of chronic homelessness are substance abuse disorders and mental illness.

Health problems in these three domains — physical illness, mental illness and substance abuse
disorders — are intimately related. For example, surveys of the health status of homeless people
demonstrate repeatedly that the single most common disorder is substance abuse. This in turn
contributes to a wide range of other health problems resulting from self-neglect and poor hygiene,

National Symposium on Homelessness Research 8-5

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

nutritional deficiencies, trauma, exposure, accidents, victimization, toxic effects of ingested substances
(e.g., hepatic cirrhosis due to alcohol) and infections (e.g., bacterial endocarditis, hepatitis and HIV
infection due to IV drug use). Studies also demonstrate the poor general health status of severely
mentally ill homeless people. They are more prone to neglect personal hygiene and their basic health
care needs, and to have poor nutrition. Seriously mentally ill homeless people have been found to be at
higher risk for tuberculosis (Sakai et al., 1998) and HIV infections (Susser et al., 1993).

Another example of how many of these problems overlap is in the area of impairment of physical
function. Despite their young age (mean age in the mid 30's), half of homeless adults state that they are
limited in performing vigorous physical activities (Gelberg, Linn & Mayer-Oakes, 1990). Further, many
are limited in moderate physical activities (21 percent), walking several blocks (28 percent), bending,
lifting, or stooping (28 percent), type or amount of work (43 percent), or all types of work (29 percent).
Functional disability might be due to any acute or chronic physical illness. Just as likely, this impairment
might be the result of mental illness. In fact, it is difficult to tease out the differential effects of these two
aspects of illness, since they are both multifaceted and both influence one another. For example, if a
homeless person experiences physical impairment, this might be due to cardiopulmonary disease, or to
the vegetative symptoms of severe depression.

The remainder of this section will address the epidemiology of health problems of people who are
homeless. Although there is overlap among the different problems, they will be divided for the sake of
clarity into the following categories: acute illnesses; chronic physical conditions; communicable
diseases; dental problems; substance abuse disorders; chronic mental illness; and violence. Because of
special issues related to gender and age, sections are also included on: women's health; health of
children and teens; and health of the elderly.

Acute Illnesses

About two-thirds of the problems homeless people present to primary health care sites are acute in nature
(Wright, 1990). Some of these maladies, especially minor respiratory infections, could easily be self-
treated by people in homes, with over-the-counter medications, appropriate nutrition, bedrest and a little
bit of medical advice — all of which are inaccessible to those without homes. The three most common
acute illnesses that afflict homeless people (Wright, 1990) are usually a direct consequence of the
homeless condition:

• respiratory infections (ranging from colds to influenza, pneumonia and pleurisy)

• trauma (lacerations, wounds, sprains, contusions, fractures, burns, etc.)

• minor skin ailments (including sunburn, contact dermatitis, psoriasis, corns and calluses)

Exposure to the elements and crowded shelter conditions increases the risk of contracting respiratory
infections and the risk of complications. Most of the trauma is directly related to life on the streets. And
dermatological problems are frequently due to exposure to the elements, shelter conditions, lack of
hygiene facilities, and inappropriate footwear, among other factors. Other acute problems that can also
be traced to the homeless condition include infestations (such as lice or scabies), nutritional deficiencies,
and acute gastrointestinal disorders.

Chronic Physical Conditions

The other third of the physical health problems of homeless people are chronic problems, such as
hypertension, diabetes, gastrointestinal problems, neurological disorders, chronic obstructive pulmonary

8-6 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

disease, arthritis and other musculoskeletal problems (Wright, 1990). Many of these illnesses are also
common among the housed population, but are made worse by the stress and exposure of homelessness
as well as by the lack of access to ongoing treatment. Studies comparing housed and homeless
populations have shown that people without homes are more likely to suffer from a chronic health
problem (Wright, 1990).

One chronic physical disorder considered to be classically characteristic of the homeless condition is
peripheral vascular disease (Scanlan and Brickner, 1990) — venous or arterial deficiencies in the
extremities, including such disorders as varicose veins, phlebitis, thrombosis, swollen ankles, cellulitis of
the extremities and gangrene. This is primarily due to people being on their feet all day, the lack of
opportunities to elevate feet and legs, and often having to sleep in a sitting-up position.

Communicable Diseases

Communicable diseases are of particular concern for two reasons: the potential for rapid spread among
people living in crowded shelters or unsanitary conditions; and the health risk to the general public.
About one out of every five HCH clients has an infectious or communicable disease (Wright, 1990).
Most of these disorders are relatively minor, such as lice or scabies infestations, other skin diseases, etc.
However, serious respiratory infections were found in almost four percent, sexually-transmitted disease
(STD) in about three percent, and active tuberculosis (TB) infection in about one percent (Wright, 1990).
Contagious diseases, such as tuberculosis (Brickner et al., 1985; Wright et al., 1987; Zolopa et al., 1994)
and HIV infection (Torres et al., 1990; Zolopa et al., 1994), are more common among homeless people
than in the general population.

Tuberculosis

Five factors contribute to a heightened risk for TB among homeless persons (National Health Care for
the Homeless Council, 1994):

1. Insufficient access to preventive services and health care, including lack of outreach, case
management or other enabling services which would improve the likelihood of receiving effective
care.

2. Prevalence and incidence of tuberculosis among other homeless persons, increasing possibility of
exposure.

3. Crowding and insufficient ventilation in shelter environments.

4. Increased prevalence of other health conditions which suppress the immune system, such as HIV
infection, poor nutrition, untreated diabetes, chronic obstructive pulmonary disease, alcoholism, drug
abuse and psychological stress.

5. Incomplete drug therapy, due to difficulties of compliance in a homeless environment, which leads to
development of drug resistant bacteria.

As a result of this increased risk, the prevalence of TB infection among homeless adults ranges from 32
percent in San Francisco (Zolopa et al., 1994) to 43 percent in New York (McAdam et al., 1990). The
rate of active TB among men in a New York shelter clinic was 6 percent (Zolopa et al., 1994). The rate
of positive TB skin tests has been found to be related to duration of homelessness (Zolopa et al., 1994;
Gelberg et al., 1997), living in crowded shelters or single-room occupancy hotels (SROs) (McAdam,
1990; Zolopa et al., 1994; Gelberg et al., 1997), area of the city (Gelberg et al., 1997), and injection drug
use (Zolopa et al., 1994). The general public is also at risk. A homeless person with undiagnosed
pulmonary TB who frequented a neighborhood bar infected 42 percent of the regular customers of that

National Symposium on Homelessness Research 8-7

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

bar (Kline et al., 1995). TB is more difficult to treat in a person who is homeless because of the
difficulty of screening, following, and maintaining treatment, and because many have multidrug-resistant
organisms (Bernardo, 1985; Brudney and Dobkin, 1991).

HIV/AIDS

The prevalence of HIV infection among the homeless population is also higher than in the housed
population. Studies reveal an HIV infection rate of 9 percent among San Francisco's homeless adults
(Zolopa et al., 1994), 1.3 percent among African American homeless women in Los Angeles (Nyamathi,
1992), 19 percent among homeless psychiatric patients in a New York City men's shelter (Susser,
Valencia and Conover, 1993), 62 percent among homeless men who visited a New York City shelter
clinic (Torres et al., 1990), and 5 percent among homeless youth in a New York City shelter clinic
(Stricof et al., 1991). Recent research (Smereck and Hockman, 1998) has also shown that rates are
higher for homeless people living on the street (19 percent of population studied) than those in other
living situations such as shelters (11.2 percent of those studied). Rates also differed by gender and race,
with exceptionally high HIV+ rates for on-the-street homeless Hispanic males (29 percent) and females
(32 percent) and for on-the-street homeless black females (38 percent).

Another recent study (Somlai et al., 1998) found that different factors were associated with HIV risk
levels among homeless men and women. In men, high-risk patterns were associated with negative
attitudes toward condom use, low levels of intention to use condoms, high perceived risk of AIDS, and
low perceived self-efficacy for avoiding risk. Women at high risk of HIV infection had greater life
dissatisfaction; were less optimistic and held more fatalistic views about the future; held more negative
condom attitudes; perceived themselves to be at risk; and frequently used alcohol, marijuana, and crack
cocaine.

Hepatitis

Viral hepatitis has become a major concern to clinicians providing care to homeless persons. The
hepatitis C virus (HCV) is now the most common chronic blood-borne infection in the United States
(CDC, 1998). Although the incidence of HCV infection is declining in the general population, its
prevalence remains high in particular subpopulations, especially those involved in high risk behavior of
intravenous drug use and unprotected sex. There currently is no significant body of research on HCV
specific to the homeless population, but homeless health care clinicians have been seeing a rapid increase
in the number of chronic cases, in part because of increased screening. According to these clinicians, the
incidence of HCV infection is higher in health care settings serving a larger proportion of injecting-drug
users or HIV-infected individuals (HCH Clinicians' Network, 1999). "Since HCV-infected persons can
remain asymptomatic for 20-30 years, many are unaware of their condition, complicating infection
control and prevention of ultimately life-threatening sequelae." (HCH Clinicians' Network, 1999)

Due to the high prevalence of intravenous drug use and unprotected sex, homeless youth and adults are at
also at great risk for hepatitis B. Little has been published on rates of hepatitis B positivity within
homeless populations, but the limited literature notes that homeless adolescents are at high risk (Busen
and Beech, 1997; Morey and Friedman, 1993; Wang et al., 1991). Experience suggests that all homeless
children, youth, and probably most adults should be immunized against hepatitis B and high-risk persons
should be tested for hepatitis B and C infection.

8-8 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

People experiencing homelessness are also at risk for hepatitis A, due to overcrowding in shelters as well
as eating out of garbage cans, both of which heighten the risk of fecal-oral spread of this disease. In fact,
an outbreak of hepatitis A was found in a shelter in Vienna (Kern et al., 1986).

Dental Problems

One of the more overt identifiers of poverty in the United States is poor dental health (Gelberg, Linn &
Rosenberg, 1988) and it is one of the major health problems reported by homeless individuals (Mowbray
et al., 1986). Ten percent of homeless clinic patients have been found to have poor dental health, a rate
thirty-one times that found in the general population (Wright and Weber, 1987). Homeless persons
living in the community are one-third as likely as domiciled adults to have obtained dental care in the
past year, and consequently are twice as likely to have gross dental decay (57 percent versus 23 percent)
(Gelberg, Linn & Rosenberg, 1988). More than half of homeless persons have grossly decayed teeth
(Gelberg, Linn & Rosenberg, 1988).

Given this high rate of dental disease, dental care should be an integral part of any health care services
package developed for homeless people. Unfortunately, dental care is not always given the significance
it deserves within the general health care arena. Some may even think dental care for people who are
homeless is a luxury. Yet the impact of dental disease and lost teeth goes beyond the general health
implications of infection and pain. Nutrition is affected because people without teeth are severely
limited in what they can eat, resulting in fatigue and additional health problems. There is also an
important link between the condition of the mouth and teeth and an individual's self-esteem, with the
resulting impact on their emotional health and
social interactions. This in turn functionally
affects their ability to obtain employment. As a
formerly edentulous client at one HCH dental
clinic commented after getting a full set of
dentures, "It's hard to get a job if you can't smile"
(McMurray-Avila, 1997).

Substance Abuse Disorders

Epidemiological research consistently

demonstrates, and service providers can confirm,

the major impact of substance use disorders in

homeless populations. Based on clinicians'

reports, Wright (1990) estimated that of people

seeking primary health care from HCH programs,

38 percent were alcohol abusers and 13 percent

abused other drugs. Surveys of homeless people

in general suggest higher rates: the Baltimore

Homeless Study (Breakey et al., 1989) produced

estimates of rates for alcohol use disorders of 67

percent and 26 percent for men and women

respectively and rates of 29 percent and 11

percent for men and women for other drug use

disorders. Robertson et al.(1997) found lifetime

rates of alcohol use disorders of 71 percent in men and 63 percent in women in Alameda County,

California. Rates for other drug use disorders were 53 percent and 51 percent. An examination of

The intoxicants used by homeless people vary from
place to place and time to time, following the trends
in the wider society. Thus, as the cocaine abuse
epidemic increased through the 1980s and 1990s, the
amount of cocaine use and abuse in the homeless
population increased also. However, in nearly every
report, alcohol is still the principal drug of abuse in
most places. The drugs of greatest concern in
homeless people, from a public health standpoint,
are alcohol, heroin and cocaine. Alcohol abuse and
dependence are associated with a wide range of
health complications involving the liver, the nervous
system and the heart. This is in addition to the social
deterioration, loss of economic productivity,
vulnerability to accidents and victimization that are
common outcomes. Heroin dependence, in addition
to its social, legal and economic effects on the
person, in most cases involves intravenous
administration, with the hazards of infections such as
bacterial endocarditis, hepatitis and HIV disease
which have a major impact on an individual's health
and pose major challenges for health care services.
Cocaine, when it is administered intravenously,
poses similar risks, in addition to the social and
mental consequences of its use.

National Symposium on Homelessness Research

8-9

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

numerous studies to date (Koegel, Burnam & Baumohl, 1996) concluded that about half of homeless
people studied have had a diagnosable substance abuse disorder at some point in their lives, with a
history of alcohol abuse occurring in almost half of single adults who are homeless, and a history of drug
abuse in approximately one-third.

Chronic Mental Illness

In the mid-1980s there were several well-designed prevalence studies using standardized diagnostic
methods to determine rates of mental illness in homeless populations of major American cities (Institute
of Medicine, 1988; Fischer and Breakey, 1991). Research indicates that prevalence rates of specific
psychiatric disorders vary in different subgroups of homeless people and from place to place, but a broad
consensus emerged that of homeless people residing in shelters, about one third had significant mental
illnesses (Koegel, Burnam & Fair, 1988; Breakey et al., 1989; Susser, Struening & Conover, 1989;
Smith, North & Spitznagel, 1992, 1993).

Data from the Baltimore Homeless Study (Breakey et al., 1989) are typical: approximately 35 percent of
men and 48 percent of women were found to have a major mental illness. Schizophrenia was diagnosed
in 9 percent of men and 16 percent of women, and major mood disorders in 17 percent of men and 25
percent of women. Note that these mentally ill people varied in their degree of disability, as do mentally
ill people in general. If criteria of extensive histories of inpatient admissions and significant functional
impairment are applied, the number who are "severely and persistently" mentally ill is many fewer. It is
this group who present the greatest needs for treatment and rehabilitation. They were estimated to
represent between 20 and 25 percent of homeless people by Koegel, Burnam & Baumohl (1996). In the
Baltimore sample, they comprised 17 percent of men and 24 percent of women (Breakey et al., 1989).

Violence

Violence in the lives of homeless persons is a major factor for understanding critical pathways from
childhood and adulthood into homelessness (Bassuk, Melnick and Browne, 1998; Kipke et al., 1997;
Link et al., 1995; North, Smith and Spitznagel, 1994; Toro et al., 1995). Such violence experienced
during childhood and adolescence often continues once individuals become homeless as a result of their
lack of protection and personal security. These experiences lead to both acute and chronic health
conditions (Gelberg, Linn and Mayer-Oakes, 1990) and potentially affect trust building and subsequent
adherence with preventive and ongoing health care (Goodman et al., 1997).

Women's Health

Health services for homeless women are severely lacking (Institute of Medicine, 1988), and yet
pregnancy and recent births are risk factors for becoming homeless (Weitzman, 1989). Ninety -five
percent of homeless women are sexually active (Nyamathi, 1993), and yet 72 percent do not use birth
control (Gelberg & Linn, 1985). Less than 10 percent use condoms, despite lifestyles that place them at
great risk for HIV/ AIDS and other sexually transmitted diseases (Gelberg & Linn, 1985; Shuler et al.,
1995; Brickner et al., 1990). This is evidenced by the fact that 60 percent of homeless family planning
clinic users had a history of a sexually transmitted disease (STD), and 28 percent had a history of pelvic
inflammatory disease (PID) (Shuler et al., 1995). In addition, more than one-fifth have not had a Pap
smear in the past five years (Gelberg & Linn, 1985) compared to less than 9 percent of women in the
general population (Hay ward et al., 1988). This is alarming given that 23 percent of homeless family
planning clinic users had an abnormal Pap smear (Shuler, 1991).

8-10 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

If the homeless condition is unhealthy for people in general, clearly it is even more dangerous for a
pregnant woman. Homelessness brings high risks for complications during pregnancy due to lack of
prenatal care, poor nutrition, stress and exposure to violence. Normal physiological changes of
pregnancy often become pathological, signs of potential complications go unnoticed or unattended, and
the minor discomforts of pregnancy are exacerbated by the homeless environment (Killion, 1995). These
complications become even more pronounced when the woman is a substance abuser, is mentally ill or is
HIV+. Based on studies of women's obstetrical history, 74 percent have had children (Burnam & Koegel,
1989; Shuler et al., 1995) and 54 percent are currently at risk for unintended pregnancy (Shuler et al.,
1995). Homeless women are more likely to be pregnant (11 percent of homeless women age 20 and over,
and 24 percent of 16- to 19-year-old homeless youth) than their poor but housed peers (five percent)
(Chavkin et al., 1987). In addition, they are more likely to receive inadequate prenatal care than poor but
housed women (56 percent versus 15 percent) (Chavkin et al., 1987).

It follows that homeless women are more likely than impoverished housed women to have poor birth
outcomes (Paterson and Roderick, 1990; Shuler et al., 1995; Weitzman, 1989; Wright and Weber, 1987),
with one study showing a difference in low birth weight newborns of 16 percent for homeless mothers
versus seven percent for non-homeless mothers (Chavkin et al., 1987). In New York City, infant
mortality was highest among homeless women (24.9 per 1,000 live births) as compared to poor housed
women (16.6 per 1,000 live births), and non-poor housed women (12.0 per 1,000 live births) (Chavkin et
al., 1987). In Great Britain, while homeless women had higher rates of premature births (11 percent vs.
seven percent of the general population), their rates of infant mortality were the same as those of housed
women (Paterson & Roderick, 1990).

Homelessness puts women at risk for trauma due to violence, often echoing abuse suffered earlier in life.
Physical and sexual abuse in family and other interpersonal relationships have been identified as both a
cause and a consequence of homelessness in the lives of women (Hagen, 1987; Stoner, 1983). In one
study of homeless and poor housed women, 67 percent reported severe physical violence by a childhood
caretaker, 43 percent reported childhood sexual molestation, and 63 percent reported severe violence by a
male partner (Browne & Bassuk, 1997). Women on the streets are often victims of assault, both physical
and sexual. Those who are mentally ill or under the influence of drugs or alcohol are even more
vulnerable to attack, and less likely or able to seek help afterwards (Burroughs et al., 1990).
Unfortunately, even being in a shelter does not always protect women from violence, especially in large
public shelters that also house men. And homeless women who are in relationships are just as likely as
housed women to be battered by their partner, becoming victims of domestic violence without the benefit
of the "domestic" dwelling (Burroughs et al., 1990).

Health of Children and Youth

Homeless children are more likely to suffer from acute health problems, than from chronic conditions.
The most common illnesses in children seen by HCH projects are, in approximate order of frequency:
minor upper respiratory infections; minor skin infections; ear infections; gastrointestinal problems;
trauma; eye disorders; and lice infestations (Wright, 1990). As might be expected in families that move
frequently, homeless children are often behind in their immunizations (Wood, 1992). And without easy
access to health care services, chronic illnesses such as anemia, asthma and recurrent otitis media often
go undiagnosed and untreated. Poverty has been seen to have a significant impact upon children's health,
achievement, and behavior (Brooks-Gunn and Duncan, 1997). The effects of homelessness on normal
childhood development have been documented to include academic difficulty (due to missing school)
(Eddins, 1993) and behavior problems (Wood, 1992), as well as growth delay (Fierman et al, 1991),

National Symposium on Homelessness Research 8-1 1

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

developmental delay, anxiety, depression and learning difficulties (Aber et al., 1997; Bassuk, Rubin &
Lauriat, 1986; Eddins, 1993).

Homelessness among adolescents is more frequent than is generally realized (Ringwalt et al., 1998).
Homeless youth, sometimes known as runaways, throwaways or simply "street kids," suffer from
illnesses directly related to a lifestyle on the streets that is characterized by violence and deprivation
(Kennedy et al., 1990; Robertson, 1996). Street youth have often been victims of physical and sexual
abuse and family chaos, and have been found to have a greater number of psychological and physical
problems than the general adolescent population (Sherman, 1992). Many engage in "survival sex,"
exchanging sexual favors for food, clothing or shelter, making them vulnerable to sexually-transmitted
diseases, including HIV, as well as unintended pregnancies (Rew, 1996). Health problems most
commonly seen by clinics serving this population include (in approximate order of frequency): violent
and traumatic injury; substance abuse; sexually-transmitted diseases, including hepatitis and HIV/ AIDS;
psychiatric disturbances; skin infestations; ignored pregnancies; "unwell" babies; and common chronic
illnesses that have been exacerbated by the lack of simple care (Kennedy et al., 1990).

A study of homeless and poor housed youths found that approximately 32 percent had a current mental
disorder accompanied by impairment in function, but use of mental health services was low (Buckner and
Bassuk, 1997). Psychiatric disorders are likely to be ignored, covered up or denied by adolescents. Their
frequent past histories of abuse and neglect, their involvement in antisocial lifestyles and neglect of their
education have grave implications for their personality development and maturation into adulthood.

Health of the Elderly

Relatively few homeless people over age 65 are seen in health care sites serving homeless people — only
2.7 percent in 1996 (U.S. Department of Health and Human Services, 1998a). This could be due either to
early mortality or to the additional benefits and assistance available once a person reaches 65 (allowing
for access to income, housing and health care). Although their numbers are few, "the aged homeless are
of special concern because of their vulnerability to victimization while on the streets and in shelters, their
frailty due to poor physical health, and the reluctance of community senior centers to accept them as
participants" (Ladner, 1992). As would be expected, many of their health problems are chronic
conditions associated with aging, such as COPD, PVD, hypertension and heart disease (Blakeney, 1991;
Gelberg, Linn & Mayer-Oakes, 1990; O'Connell, Summerfield and Kellogg, 1990 ). The majority suffer
from alcoholism, but mental illness is somewhat less common than in the general homeless population
(Blakeney, 1991).

System Adaptations Designed To Overcome Access Barriers

Compounding the increased risk for illness or injury, there is evidence that homeless people encounter
major obstacles to obtaining needed medical and psychiatric services. The majority of homeless adults
state that they did not obtain needed medical care in the previous year (Gelberg and Linn, 1988;
Robertson and Cousineau, 1986). Even among those with a chronic medical condition, half had not seen
a doctor within the previous year (Robertson, Ropers and Boyer, 1985). Organizations providing
services to homeless people have described numerous difficulties in accessing substance abuse treatment
for their clients (Williams, 1992).

Since the mid- 1 980' s, significant advances have been made in the development of effective delivery
systems for health services to people who are homeless. The support of several agencies of the U.S.
Department of Health and Human Services — often through programs authorized by the Stewart B.

8-12 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

McKinney Homeless Assistance Act of 1987 — has been instrumental in these advances. The Bureau of
Primary Health Care's Health Care for the Homeless (HCH) program has assisted more than 130
communities in providing comprehensive health services to people who are homeless, with a special
focus on developing systems that directly address the barriers to access homeless people face.

Some of these barriers to access are related to external factors such as lack of transportation (Robertson
& Cousineau, 1986). Others are internal, for example, denial of existence of a health problem, lack of
awareness of available services, or active avoidance due to fear or distrust of large institutions. Because
an exhibition of toughness is necessary in order to survive on the streets, homeless persons may at times
deny that they have health problems in an attempt to maintain a sense of their own endurance. People
with substance abuse disorders or mental illness may deny having a problem or be unaware of the
severity of it.

Even when aware of their problem and of available services, many homeless people are distrustful of any
offers of help due to previous negative experiences with the health care and social services systems.
They may be too embarrassed to have medical professionals see them in a condition of poor personal
hygiene. Or they may avoid seeking health care because of the fear of having their meager financial
resources taken away to pay for the services they receive, or fear of authority figures (Stark, 1992),
including Immigration and Naturalization authorities, child protective service workers (by runaway
teenagers and homeless women with children), and police (by drug abusers or ex-convicts) (Jahiel,
1992).

Service Delivery Locations

In order to overcome these barriers, health care projects serving homeless people have developed
adaptations related to locations of service delivery, with options ranging from mobile to fixed-site
services. Mobile approaches — both street outreach and use of mobile units — respond especially well to
the barriers mentioned above, finding and engaging people who would otherwise not receive health
services. Fixed-site locations include: shelter-based services; community health center or hospital-based
clinics with special accommodations for homeless people; and free-standing HCH facilities such as
clinics, respite units, drop-in centers or residential programs. Current federally-funded HCH projects
tend to use more than one approach, frequently combining street outreach with fixed-site locations in
shelters or free-standing clinics (Cousineau et al., 1995).

Scheduling Of Services

Another significant obstacle to access relates to times when services are offered. Mainstream services
depend on scheduled appointments, which are often hard for homeless people to keep, due to competing
priorities for survival, such as finding day labor, a free meal or a shelter bed for the night (Gelberg,
Gallagher, Andersen & Koegel, 1997). People who are homeless also lack access to telephones to make
appointments or change them if necessary. For this reason, scheduling of services needs to coincide with
the most convenient times for the population being targeted, and should not conflict with those times
when homeless people are normally searching for a meal or shelter. Many HCH projects set aside certain
times for walk-in clinics, while other times are designated for scheduled follow-up appointments with
clients who have an established history of care. Outreach schedules need to be even more flexible, often
taking place during early morning or evening hours, depending on the population and the setting
(McMurray-Avila, 1997).

National Symposium on Homelessness Research 8-13

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Financial Barriers

Lack of financial resources or health insurance and lack of documentation constitute additional access
barriers that affect how services need to be structured and delivered. One-fifth of homeless adults who
had not obtained needed medical care stated that this was due to inability to pay for medical services
(Cohen, Teresi & Holmes, 1988; Robertson & Cousineau, 1986). Only one-sixth (Bassuk, Rubin &
Lauriat, 1984; Fair, Koegel & Burnam, 1986; Robertson, Ropers & Boyer, 1985) to one-third (Fischer,
Shapiro & Breakey, 1986; Miller & Lin, 1988) of people who are homeless have any form of health
insurance, and most have no cash resources at all (Koegel & Gelberg, 1992). One decade after most of
these studies were performed, HCH projects still report that over 70 percent of the clients they see have
no financial resources for health care (U.S. Department of Health and Human Services, 1998a).
Homeless people frequently lack identification or other documentation to prove indigent status in order
to qualify for free or reduced services in mainstream health care settings. They often have had their
identification documents lost or stolen, or are living in the streets and shelters of the U.S. without legal
documentation.

Health care programs for homeless people must therefore tap into every available funding source to
eliminate this access barrier. Public funds, through Medicaid and other funding streams, have supported
health care for poor and homeless people. As public programs exert pressure to conform to models first
developed for managed care in the private sector, effective HCH projects must continue to give priority
to responding to the special needs and realities of their clients. At the same time they must strive to
address the increased needs for detailed intake, authorization and billing procedures, despite the drain on
resources of staff and time. These conflicting priorities may be a source of considerable stress to
clinicians and to program administrators. Strict adherence to a business mentality will create frustration
for staff and alienation for clients.

Cultural Competence

Access to services is also affected by language and cultural barriers and by attitudes of providers of care.
While a positive, open attitude of being culturally sensitive is necessary, it only becomes cultural
competence when it is put into practice. Practicing cultural competence involves a combination of
attitude, knowledge and skills (CASSP). An attitude jA respect is essential when working with people
who are homeless, as well as maintaining an acceptance of cultural differences among people. People
from all cultural backgrounds become homeless, so practitioners need to be willing to work with clients
of different ethnic minority groups and cultures. Knowledge of the history, traditions, values, and family
systems of these cultures is important, especially an understanding of the effects of particular cultures on
the help-seeking behaviors of people who are homeless, as well as the specific health beliefs and healing
practices of the cultures involved.

In addition to the obvious skill of language competency, skill is also needed to adjust clinical practice to
accommodate certain health beliefs and healing practices of different cultures. Cultural beliefs affect
attitudes toward disease and health, as well as offering explanations for causes of ill health, including
mental illness and substance abuse. What may be labeled "non-compliance" by a health care provider
could in reality be due to cultural differences in interpreting the diagnosis and/or treatment.

Dealing With Disruptive Behavior

An additional barrier to access is created when homeless people with histories of disruptive behavior are
actually barred from services. Homeless health care providers continually have to assess the nature of
disruptive behavior — is the person acting out due to a mental illness beyond his or her control, or is the

8-14 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

behavior intentional and meant to do harm? Again a delicate balance must be maintained between
flexibility — particularly with regard to examining and changing rules or policies that may be
inappropriate for the population in question — and the safety of the client, other clients and the staff.
What may sometimes be labeled a shortcoming of the client in terms of being "non-compliant" may
actually be a shortcoming of the system of services — non-compliance with the approaches needed to
effectively serve the clients.

Multidisciplinary Teams

One final adaptation to service delivery that health care providers must make when working with
homeless people relates back to the concept of integrated services discussed in the introduction. Most
mainstream health care organizations are primarily single-focused. They either provide medical care,
mental health services or substance abuse treatment. Few are organized to deal with the multiple issues
that are part of being homeless. When people are treated only for the "presenting problem," the
underlying cause of that problem may not be addressed. Clinical interventions with homeless people are
most effective when carried out by multidisciplinary teams (Burness Gleicher et al., 1990). The practice
of clinicians from different disciplines working together offers more chance of arriving at appropriate
diagnosis and treatment conclusions.

Health Services for Homeless Youths

Providers of health care must be aware of all of these potential barriers, making adaptations as necessary
and paying special attention to the characteristics of the population they are serving. Designing health
services for homeless youths provides a good example of this. Adolescents who are homeless and apart
from their families present significant problems for health care because of the difficulty in engaging
them, but also because of their frequent reluctance to acknowledge their need. Their status as minors,
issues of consent and confidentiality and their distrust of adults provide additional barriers to care
(Robertson, 1996) Clinicians working with this group should be well- versed in the usual health needs of
adolescents, but particularly prepared to deal with the physical and emotional effects of violence,
common and exotic sexually transmitted diseases, pregnancy and mental illness. Kennedy et al. (1990)
describe a number of principles in delivery of health care to "street kids." These include outreach to
places where adolescents congregate; immediacy, the ability to respond without delay, because a
teenager may not wait or come back again, having once expressed willingness to accept treatment;
networking, to provide the needed linkages into a range of helping services; and sanctuary, in terms of
privacy and protection. Services should be available in youth shelters, but also on the street, through
outreach, because many homeless adolescents do not use shelters (New York State Council on Children
and Families, 1984; Robertson, 1996). Health promotion, disease prevention and harm reduction
strategies focused on this group are essential.

Adapting Clinical Practices to the Homeless Condition

Based on the broad scope of health problems described above, it is clear that a full array of services must
be made available and accessible for people who are homeless. Otherwise, the care can easily revert into
"Band-Aid medicine" and miss underlying or co-occurring conditions. The following discussion covers
elements of health care encounters common to medical, mental health or substance abuse services,
including: intake and assessment; clinical preventive services; diagnosis; referrals for specialty and
inpatient care; linkages to non-health services; and follow-up to ensure continuity of care. It is important

National Symposium on Homelessness Research 8-15

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

to remember that the elements may not necessarily occur in this order, or be provided in a typical clinical
setting.

Intake and Assessment Procedures

A system that features multiple points of entry is termed the "no wrong door" approach. In such a
system, a homeless person is offered the opportunity to link with all needed services through the initial
contact — whether through a medical or dental program, street outreach, or any point in the continuum of
substance abuse or mental health services. To identify needed services, an adequate assessment of health
and social problems is necessary, including housing status and access to basic needs (food, clothing,
etc.).

In addition to the standard clinical history questions, the intake procedure should pay special attention to
the client's living situation, including questions related to sleeping location, sources of food, support
systems (friends or family), history of mental illness, use of alcohol or street drugs, exposure to violence
or abuse, cause of homelessness, and plans for getting out of the homeless situation (Usatine et al., 1994).
Answers to these questions will help determine the appropriate course of action, regardless of whether
the initial encounter involves medical or dental services, mental health or substance abuse problems.
Providers of care to homeless people also need to be alert for any possible underlying conditions that
could affect the diagnosis, proposed treatment or eventual outcome of each client's case. It is important
to note, however, that the need for a comprehensive assessment must always be weighed against the
possibility of alienating or intimidating the person being assessed.

Clinical Preventive Services

Prevention activities fall into several categories:

• Screenings for acute and chronic physical conditions, communicable diseases, mental illness and
substance abuse disorders;

• Well-child exams;

• Immunizations (for adults and children);

• Special services for women, including family planning and perinatal care;

• Health education/health promotion including self-care information for patients with particular
conditions (ranging from diabetes to addictions) and encouraging changes in behavior that will
improve or maintain health or prevent disease.

Screening. Without overwhelming clients with probing questions unrelated to the stated purpose of their
visit, screening for both physical and mental chronic conditions should be included whenever possible,
even in acute care visits. Practitioners working with homeless people constantly have to balance the
importance of preventive activities (whether screening or promoting behavior change) with the mental or
emotional state of their clients, as well as sensitivity to their past experiences with the "system." In order
to engage homeless people in ongoing care it is necessary to avoid alienating them and to focus on
establishing trust (Cousineau et al., 1995). However, screening procedures are welcomed by many
homeless people (Long et al., 1998) and should be a part of each clinical encounter within a clinical
program. Some health care programs for homeless for people have also performed screenings in shelters,
soup kitchens and other locations, to identify potentially treatable conditions in people who otherwise
might not get clinical care.

8-16 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Blood pressure screening for hypertension is routine with any physical exam. Homeless people should
also be offered TB skin testing (CDC, 1995), while recognizing the likelihood of false negatives with
people who are HF/+ (Morrow et al., 1997); routine testing for STDs, including HIV/ AIDS; breast,
cervical, skin, prostate and colon examinations; screening for glaucoma; and testing for cholesterol levels
(Weinreb, 1992). In addition to screening for physical illness, primary care providers also need to be
alert for signs of substance abuse and mental illness (Usatine et al., 1994). The CAGE is a simple but
effective screening tool for alcoholism (Ewing, 1984). Health care providers must also be trained in
routine screening of patients for victimization histories, as well as in the recognition of the physical and
mental symptoms and signs of violence among their patients (e.g., injuries and post traumatic stress
disorder) (Harris & Landis, 1997; Lam & Rosenheck, 1998; Moy & Sanchez, 1992; North & Smith,
1992; Padgett & Struening, 1992).

Well-Child Exams. Like any other children, homeless children require regular examinations and
immunizations. Working with homeless families who have children raises additional screening issues.
According to Wood, "Homeless families often cite benign acute problems as the reason for a clinic visit.
Each encounter, however, should include a history of preventive health care, developmental problems,
school problems, medical problems and past child abuse" (Wood, 1992). Because homeless families
experience many problems that could lead to child abuse — including extreme family stress, exposure of
the child to multiple caretakers, family violence, and drug or alcohol abuse — clinicians should screen for
child abuse (neglect, physical and sexual) in the history and physical examination of every child (Wood,
1992).

All homeless children should receive a PPD skin test for TB annually. Homeless children who are
African American should receive a sickle cell screening test. And children with a history of pica or
anemia should be screened for lead exposure (Wood, 1992).

Immunizations. Immunizations to prevent diphtheria, tetanus, influenza, pneumococcal pneumonia and
hepatitis A and B should be made available to all homeless adults (Weinreb, 1992). Rubella vaccination
should be offered to homeless women of childbearing age who are not pregnant and who are antibody
negative, and who have no other contraindications for vaccination (Weinreb, 1992). Homeless children
should receive the HIB (Haemophilus Influenza B), DPT (Diptheria, Pertussis, Tetanus), OPV (Oral
Polio Vaccine), and MMR (Measles, Mumps and Rubella) vaccines according to the routine guidelines
of the American Academy of Pediatrics Committee on Infectious Disease (Wood, 1992).

Women's Health. The importance of preventive care for homeless women (gynecological exams, family
planning and perinatal care) is made obvious by the research cited above. McNally and Wood (1992)
recommend a comprehensive approach to providing perinatal care and family planning for homeless
women, with special emphasis on awareness of potential complications, screening for alcohol/drug use,
HPV7AIDS and other STDs, and use of multidisciplinary teams to include outreach and case management,
as well as clinical care (McNally & Wood, 1992).

Health Education/Health Promotion. Health education and health promotion to prevent communicable
diseases is especially vital in the homeless population, given the increased risk factors, yet the
characteristics and lack of resources of homeless people present an unusual challenge to health educators.
Many homeless people are preoccupied with their current difficulties and by temperament are not future-
oriented. They may find it difficult to make a short term sacrifice for a long term benefit. It is clearly
unrealistic to expect people who are homeless to make changes in behavior based only on the knowledge
that it's "bad for their health." For example, an over-reliance on distribution of printed materials would

National Symposium on Homelessness Research 8-17

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

not be effective with this population. However, provision of resources (such as condoms, bleach kits or
syringes) will facilitate the changes of behavior necessary to prevent HIV/ AIDS or other STDs.

Self-help approaches, such as those used in mental health self-help agencies (Segal et al., 1998) orl2-step
programs, are one way to reach people and provide ongoing support for behavior changes. Activities that
involve one-to-one personal interaction or group interaction, such as support groups, can be successful,
given the isolation many homeless people feel and the need for meaningful human contact (Tsemberis,
1996). The use of "peer educators" in drug abuse prevention with homeless youth (Fors & Jarvis, 1995)
and "peer health advisors" to improve compliance with initial clinic visits for homeless adults newly
tested positive for TB or HIV (Peterson et al., 1993) are examples of successful and innovative health
education approaches that involve the target population directly.

Another avenue to health promotion is through education of other service providers. For example,
teaching shelter and meal providers about preparation of healthy meals will probably have more impact
on the nutrition of homeless people than giving them brochures on the important food groups.
Surveillance of health and safety conditions in shelters and other service sites will help avoid potential
accidents and injuries, as well as preventing communicable diseases, such as tuberculosis (Mayo et al.,
1996). Health care or shelter staff who work with families also need to be aware of potential child abuse
and neglect, armed with strategies from education to incident reporting.

Diagnosis

In the practice of diagnosis, three specific accommodations will be mentioned here related to: 1) the
clinical exam; 2) recognizing multiple diagnoses; and 3) availability of diagnostic tools such as
laboratory testing and radiology.

Clinical Exam. Medical care providers need to be especially sensitive to issues of hygiene when
involved in physical exams with people who are homeless. Although some clients, particularly those
with severe mental illness, may be oblivious to their unwashed condition, many are quite embarrassed. A
high tolerance and understanding on the part of the provider, combined with availability of shower
facilities (as well as clean socks and other clothing), will go a long way towards developing an
environment in which homeless people can feel comfortable and welcome. This issue continues to stand
as a major barrier for homeless people attempting to receive care in mainstream settings.

During the clinical exam, the provider will need to be alert for those conditions which commonly occur
as a result of homelessness — upper respiratory tract infections, trauma, skin disorders, musculoskeletal
problems and dental disease — regardless of what was presented as the chief complaint. In addition,
providers should be on the look-out for common chronic conditions such as hypertension, gastrointestinal
and neurological problems, peripheral vascular disease and obstetric/gynecologic conditions (Usatine et
al., 1994). Because homeless people frequently have lost glasses or had them broken or stolen, vision
should also be checked. Serious vision problems have been reported by nearly one-quarter of people who
are homeless (Gelberg & Linn, 1989).

Evaluating Psychiatric Symptoms Requires Sensitivity To Each Person 's Special Situation. There may
be a risk of either over-diagnosing or under-diagnosing treatable conditions. For example, suspiciousness
in a homeless person does not necessarily indicate paranoia, but may be an understandable consequence
of living on the streets. Conversely, low mood and disturbed sleep should not readily be dismissed as
normal reactions to bad circumstances; they may be symptoms of a treatable depressive illness.

8-18 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Recognizing Multiple Diagnoses. Primary care practitioners need to pay special attention to identifying
multiple diagnoses, avoiding isolated diagnoses that may miss co-occurring or underlying issues. This is
true whether the co-occurring diagnoses are all physical in nature or combine physical, mental health
and/or substance abuse diagnoses.

Availability of Diagnostic Tools. Accurate diagnosis often depends on the availability of laboratory
testing and radiology. Making these services easily accessible is essential when working with homeless
people. In some cases this may include providing transportation to a site where the testing can be
performed or x-rays taken.

Follow-Up to Assure Continuity of Care

Successful outcome when working with homeless people depends on more than just accurate diagnosis
and quality treatment. Frequently, success hinges on the client's ability to follow through with the
recommended treatment. Care providers face numerous obstacles in supporting this ability and
establishing continuity of care. In addition to barriers already listed, additional complicating factors
include:

Competing Needs and Priorities. People who are homeless may place a greater priority on fulfilling
their basic needs for food, shelter, hygiene, and income than on obtaining needed health services or
following through with a prescribed treatment plan (Ball & Havassy, 1984; Gelberg & Linn, 1988;
Gelberg, Gallagher, Andersen & Koegel, 1997; Robertson & Cousineau, 1986; Sacks, Phillips &
Cappelletty, 1987). Keeping follow-up appointments necessary for continuous, comprehensive care is
also difficult for homeless people due to their competing needs and different time orientation (Koegel &
Gelberg, 1992). Although we typically think of homeless people as having an inordinate amount of time
on their hands, often they must deal with the varied schedules and locations of several service facilities to
ensure that all their needs are met (Koegel & Gelberg, 1992).

Mobility. While many homeless persons are long-term residents of their communities, others are quite
mobile within or between cities or states in their search for subsistence resources. This mobility makes
continuity of care difficult (Brickner et al., 1984; Koegel & Gelberg, 1992).

Difficulty Keeping and Storing Medication/Food. The conditions of street life affect compliance with
medical care. There is usually a lack of proper sanitation (Baxter & Hopper, 1981); lack of a stable place
to keep medications safe, intact, and refrigerated (Brickner et al., 1984; Wright & Weber, 1987); and an
inability to obtain the proper food for a medically indicated diet to deal with conditions such as diabetes
mellitus or hypertension (Brickner et al., 1984; Wright & Weber, 1985).

Discharge Planning. Homeless people who have been hospitalized are often discharged directly from
the hospital to the streets with inadequate discharge planning to assure conditions for safe recuperation.
Even homeless mothers are discharged to the streets with their newborn infants soon after childbirth.
Readmission of homeless patients to hospitals is not uncommon (Stark, 1992).

Attitudes of Health Care Providers. People who are homeless may sense from the medical profession a
reluctance to treat them due to their poor hygiene or mental illness, or because of assumptions that they
come to hospitals for shelter and not for a medical problem (Baxter & Hopper, 1981). Being treated with
a lack of respect does not encourage follow-up care or compliance with care.

National Symposium on Homelessness Research 8-19

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Respite Care. One of the most valuable activities for promoting continuity of care is the availability of
respite care facilities for homeless persons who are not considered sick enough to be hospitalized, but are
too sick to stay on the streets. Shelters and streets are often the sites to which homeless patients are
discharged from hospitals (Goetcheus et al., 1990; Stark, 1992). Since shelters are usually open only at
night, where do ill homeless persons go for rest, nutrition and simple basic care? Convalescent facilities
are needed so that homeless persons, after being provided medical, surgical or obstetrical care are not
discharged from outpatient settings or hospitals to the streets when their recuperation requires running
water, a bed, refrigeration, or proper nutrition (Stark, 1992). Respite care ensures that homeless persons
receive care that most others, with homes and families, receive routinely (Goetcheus et al., 1990).

Referrals for Specialty Care and Inpatient Care. Although the focus here has mostly been on primary
care and the importance of early intervention, the realities of homelessness often result in illnesses or
injuries being left untreated, resulting in numerous complications requiring more specialized attention.
Homeless people need easy access to specialty care and hospitalization to deal with these situations.
Homeless health care providers work hard to establish relationships with public and private health care
institutions to obtain this access. However, providers in those institutions who are not familiar with the
homeless population may need support, advice or training from homeless health care providers. In some
cases, client advocates from a homeless health care project may need to accompany clients when they are
referred to those institutions, to assure appropriate care.

Linkages to Other Services. The comprehensive assessment mentioned earlier provides the foundation
for determining what linkages are needed. Establishment of referral relationships with other service
providers, and a system of case management to coordinate those services, help assure the effectiveness of
care given for physical or mental health problems. Given the negative impact that homelessness has on
health and health care outcomes, clearly the most significant difference between treating homeless people
and the general population is the need to include elimination of homeless conditions as part of any
treatment plan. For this reason, linkages to other services — including transitional or permanent
housing — is an essential element of care. (The sections below on services for substance abuse and
mental illness will deal with this in more detail.)

Specific Adaptations for Treatment of Physical and Mental Illnesses

In the sections that follow, primary care (medical and dental), treatment for substance use disorders,
treatment of serious and persistent mental illnesses and treatment of patients with co-existing mental
illness and substance use disorders (the "dually diagnosed") will be considered in turn.

Primary Care Services

Clinical protocols for primary care treatment of specific physical illnesses or injuries are frequently the
same for homeless people as for the general population. Variations from standard protocol are most
often related to improving the possibility of compliance with treatment by taking into consideration
complications of the patient's living situation or co-occurring diagnoses, including multiple physical
illnesses, substance abuse or mental illness.

Medications

One of the most common changes in treatment is found in prescribing practices that are adjusted to
accommodate the homeless environment. For example, medications that can be given in larger doses

8-20 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

over a shorter period of time may be more effective (e.g., injections vs. oral medications). People
without homes usually have to carry their belongings with them at all times and supplies of medication
that must be taken over a long period of time may be lost or stolen. Another alternative is to consider
giving the patient just enough medication to last until the next scheduled visit. The promise of receiving
medications at a future visit may be an incentive for the patient to return. When possible, once-daily
dosing is best (Usatine et al., 1994). Medical and dental providers also need to be sensitive to possible
substance abuse issues when prescribing medications. Collaboration with substance abuse staff is
essential in order to avoid prescribing narcotics or other medications inappropriately, while still assuring
adequate pain management.

The importance of compliance with medication regimens for TB in order to prevent development of
multi-drug resistance has resulted in programs of directly-observed therapy (DOT) for clients with active
TB and directly-observed preventive therapy (DOPT) for those who have been infected. In both cases,
patients are given each dose of medication directly by health care providers, sometimes even if it means
finding the patient on the street (Caminero et al., 1996; Chaulk et al., 1995; McAdam et al., 1990; Pablos-
Mendez et al., 1997). Incentives have also been used to enhance DOT (Mangura et al., 1997), including
monetary incentives (Pilote et al., 1996).

Describing all the possible alternative treatment protocols for every illness or situation would fill up
numerous volumes (e.g., see O'Connell & Groth, 1991, for a complete manual of information on
common communicable diseases in shelters). Instead we will illustrate some of the problematic
situations encountered in treating homeless people by reviewing some of the recommendations clinicians
have made for treatment of four common chronic medical conditions and dental health

Hypertension. Fleischman and Farnham (1992) state that the difficulty of follow-up in the homeless
population renders impractical the traditional recommendation of multiple blood pressure determinations
before treatment for hypertension. Beginning treatment with dietary changes is also futile, since food at
shelters and in soup lines is high in sodium and fat. Thresholds for starting drug therapy must be
individualized, considering diminished compliance, poor follow-up, and compounding life-style
variables, such as alcohol abuse. In homeless alcoholics with hypertension, referral for alcohol
detoxification/treatment may be more appropriate than medications for hypertension. Many patients will
refuse diuretics because of poor access to bathroom facilities (Pianteri et al., 1990). Proper storage and
safe-keeping of pills is an issue, with pills often being lost or stolen. If kept in a pocket, they may be
pulverized by the movement of constant walking (Filardo, 1985).

When used, the ideal medication should incorporate the following considerations: once-daily dosing,
limited need for laboratory follow-up (i.e., avoid potassium-losing diuretics), and no rebound
phenomenon (since poor compliance and lost medications may bring on this complication) (Fleischman
& Farnham, 1992). An alternative for homeless hypertensives is the clonidine transdermal patch, which
delivers a steady therapeutic level of the medication for seven days (Michael & Brammer, 1988; Pianteri
et al., 1990; Popli et al., 1986). (See Vicic & Weber (1992) for additional guidelines for treatment of
hypertension in homeless people.)

Diabetes. Tight control of diabetes may be a dangerous goal in homeless persons, because of their
unstable eating and activity patterns (Usatine et al., 1994). Teaching a homeless person to use insulin
requires frequent follow-up appointments and careful monitoring. Most shelters do not provide clean,
accessible and safe storage places for insulin, medications, or blood glucose monitoring devices. In
addition, possession of syringes or alcohol swabs on the street or in shelters can make homeless people
into targets for theft (Scanlan & Brickner, 1990). Thus, in a homeless adult patient with noninsulin-

National Symposium on Homelessness Research 8-21

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

dependent diabetes, it may be best to avoid insulin therapy by prescribing oral hypoglycemic agents at
maximum dosages and tolerate less tight control of serum glucose (Usatine et al., 1994).

Peripheral Vascular Disease. "The most important intervention for peripheral vascular disease is a
change in lifestyle. Elevation of legs, at least during sleep, is the key to treatment. A network of shelter
referrals for beds (not pews), respite beds, or hotel vouchers may be required if the clinic is to help the
homeless client find a place to elevate his or her legs. Bus tokens should be given to limit the need for
walking long distances" (Fleischman & Farnham, 1992).

A similar practical approach can be used when addressing any of the orthopedic or podiatric problems of
homeless people. More than 10 percent of homeless adults have impaired ability to walk and 60 percent
have problems with their feet (Gelberg, Linn & Mayer-Oakes, 1990; Wrenn, 1990). These problems are
related to osteoarthritis, common in the general population as well, but also are due to the life conditions
that homeless individuals endure. They have to walk throughout the day to obtain their basic needs for
shelter, food, and clothing, often in poorly fitting shoes, without socks. Providing well fitting shoes,
changes of socks, and a bed to sleep on might seem like small interventions, but can greatly improve a
homeless person's ability to function.

Heart Disease. Treatment of heart disease in homeless adults is quite difficult. Homeless persons may
need to be admitted more often to the hospital and at a lower clinical threshold than the domiciled
population. For example, controlling sodium intake and enforcing bedrest, mainstays of therapy in the
domiciled population, are virtually impossible. Hospitalization is often required to achieve adequate
diuresis in a controlled environment where electrolytes can be monitored (Fleischman & Farnham, 1992).

Dental Health. People who are homeless need access to a full array of dental services:

• prevention — dental hygiene; education; free toothbrushes, toothpaste and floss

• assessment — exams and screening (including screening for oral cancer); x-rays

• emergency care — emergency extractions; treatment of infection

• restorative care — fillings; root canals; crown and bridge work

• prosthetics — dentures and partials

• oral surgery — for more complex cases that require a specialist

Ideally each individual would be engaged in a comprehensive treatment plan to address all of the dental
problems that have built up over the years. Unfortunately, the homeless condition is not always
conducive to follow-up with such a long-term venture. Dental staff need to have clear criteria for
determining the appropriate level of care to be provided. With a person who is clearly transient and
planning to move on, a short-term response such as an extraction may be more appropriate than initiating
a full treatment plan. If dentures are needed, a determination needs to be made regarding the ability of
the client to care for and maintain them. Setting up a complete treatment plan is most realistic for clients
who are more likely to be able to follow through, or who have been stabilized in transitional housing or
treatment programs.

Particular consideration also needs to be given to working with people with mental disorders and people
who are known to be HIV+. Special accommodations may also be necessary to care for children
(McMurray-Avila, 1997).

8-22 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Treatment Services for Substance Use Disorders

A wide variety of options and treatment models can be used to develop a responsive network of
substance abuse services for people who are homeless. A substance abuse services continuum should be
designed to meet local needs, consistent with available resources and the special needs of homeless
people (Schutt & Garrett, 1992). Barriers to accomplishing this are political, such as the NIMBY
response ("Not-In-My-Back-Yard"), or due to the limited resources available from public and private
funding agencies.

In general, the development of services for homeless addicts has lagged behind the development of
primary health care services and services for treating mental illness. To address this lack, the National
Institute on Alcohol Abuse and Alcoholism (NIAAA) supported two rounds of community demonstration
projects with funding from the Stewart B. Mc Kinney Homeless Assistance Act to identify effective
approaches for providing substance abuse treatment to homeless people (Argeriou & McCarty, 1990;
Conrad, Hultman & Lyons, 1993). The following general conclusions were drawn regarding necessary
and desirable program characteristics (Stahler, 1995):

• Need to develop treatment programs that focus not only on the addiction, but also address the
tangible needs of people without homes.

• Need to develop flexible, low-demand interventions that can accommodate clients who are not
initially willing to commit to more extended care.

• Need for longer-term, continuous interventions for this population. Aftercare needs to address not
only the maintenance of sobriety, but also the tangible needs and social isolation of clients.

• Need to match clients to appropriate treatment services based on characteristics such as educational
attainment, cultural background, severity of substance use, criminal involvement and level of social
isolation.

Although the dynamics, demographics and legal implications of addictions to different substances may
vary, the principles of treatment are the same: motivation of the person to stop using the substance,
detoxification to support the person through the withdrawal process, and rehabilitation to maintain
sobriety through a process of recovery. Homeless persons have particular needs at each of these stages,
however it is important to recognize that these are not necessarily linear stages. Engaging a homeless
person in the recovery process is a long-term undertaking, marked by numerous relapses and fluid
movement in and out of stages.

Motivating the addicted person to recognize his or her need for treatment may be the most difficult.
Street outreach workers, police officers, social workers, emergency medical staff and primary health care
workers in individual cases have important roles in persuading a homeless individual to seek treatment.
Outreach is particularly important because of the reluctance of many homeless people to seek treatment
on their own behalf. Initiating contact with homeless substance abusers on the street, in shelters, drop-in
centers, soup kitchens, etc., provides information about available services and begins the motivation and
engagement of the person into the system of services. Effective outreach workers are often formerly
homeless substance abusers who understand the situations and dilemmas of homeless people and can
provide support and encouragement, drawing on their own experiences. For homeless people the
likelihood of relapse, discouragement and fatalism is great for both patient and treatment provider. It is
part of the outreach function to instill hope in the addict that recovery is possible. Sobering-up stations
provide another form of outreach. In these small facilities, a clean sanitary, safe and supportive
environment is provided to homeless substance abusers who may not yet be ready to contemplate

National Symposium on Homelessness Research 8-23

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

detoxification. They are often staffed by individuals who are themselves recovering addicts. For a
proportion of the users of the station it provides a first step in a recovery process.

Detoxification is technically the simplest phase of treatment, although not always the most readily
available. It requires a setting where the person can go through withdrawal with the necessary support to
tolerate the unpleasant and sometimes dangerous withdrawal syndromes. Medical detoxification involves
prescribing medications to protect the patient from the withdrawal symptoms and complications. It is
most commonly done in a residential or inpatient setting, but can be done in an ambulatory program if
adequate support can be provided for the patient. Social model detoxification avoids use of medications
if possible and relies on mutual support, social learning and the 12-step principles of AA/NA. Social
model programs are less expensive to run than medical detoxification programs and reported to be
equally safe for their clients (Whitfield et al., 1978; Lapham et al., 1996).

Once detoxification has been accomplished on a residential or ambulatory basis, a long process of
rehabilitation is required. During this period the person needs protection from his or her tendency to
relapse, provided through peer and professional support and appropriate supportive living situations. The
individual needs opportunities for acquisition of new skills for everyday living, relationships and
employment and the establishment of a drug-free lifestyle. This phase of treatment is the most time-
consuming, most costly and least likely to be available and accessible for homeless people.

Elements of treatment may include individual or group counseling and education to help clients define
their needs, understand their addiction(s) and develop their treatment plan. Case management is
particularly valuable for homeless people in recovery to assist them in coordinating and negotiating the
often fragmented systems of care that exist. Case managers can help identify resources, acquire medical
or dental health care services, etc. Sometimes several elements such as counseling, education, case
management, group work, etc. may be combined into an intensive day treatment program for people who
have stable arrangements for where they will stay at night.

Although many communities have moved toward outpatient treatment to save costs, people without
homes are less likely to benefit from such a program. Treatment and rehabilitation are unlikely to be
effective as long as the person lives on the streets or in the general shelter system where the daily
pressure to use drugs or drink remains high. A range of appropriate opportunities for supportive housing
must therefore be available (NIAAA, 1991a; NIAAA, 1991b; Wittman & Madden, 1988). Residential
recovery programs can be designed for the different stages of recovery, including detoxification, primary
treatment or as a half-way house or quarterway house. Recovery houses can be based on a social model
design where residents are responsible for running the house or on a therapeutic model with greater staff
involvement. For some homeless people in recovery, a group home or adult foster care arrangement may
be appropriate. Sober housing — housing that is alcohol/drug-free — is an essential follow-up to the
treatment process. Months of hard work in treatment and recovery can be lost if the client must then
return to the streets. Sober housing may include supportive services or simply be a transitional stage to
independent housing in the community.

Throughout the entire process of recovery, peer group support is of great importance, usually provided
by groups such as Alcoholics Anonymous or Narcotics Anonymous, that provide both a theoretical
model for the process of recovery and the emotional support of other addicts. Groups exist in every city
and meetings occur every day of the week.

Total abstinence has traditionally been the goal of substance abuse services, but in many cases, addicts
are unwilling or unable to contemplate abstinence. Strategies for harm reduction serve to reduce the

8-24 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

risk of complications or other adverse effects until such time as the person is willing and able to enter the
recovery process (Marlatt, Somers & Tapert, 1993; Marlatt et al., 1997). Thus methadone maintenance
programs provide a substitute for heroin on a daily basis, with the aim of enabling the person to avoid
drug dealing and other crimes, and also to avoid some of the other health hazards of street drug use.
Needle exchange programs for IV drug users are effective in reducing the incidence of blood-borne
infections such as Hepatitis B or C and HIV, but are not legal in all states. Many programs also make
bleach kits available to IV drug users so that they can perform a rudimentary sterilization of their
syringes and needles.

As a low-demand approach to keeping people safe and alive until they are ready for treatment, wet
housing allows residents to drink in their room, while damp housing does not allow drinking on-site, but
does allow for relapses. Wet shelters, similarly, provide shelter for alcoholics who can not contemplate
abstinence, and thus enable them to avoid some of the dangers of street life while permitting them to
continue drinking. Homeless health care providers can make use of all these harm reduction techniques
to support and assist those clients who are not yet willing or able to enter a treatment process of
detoxification and rehabilitation.

Treatment Services for Serious and Persistent Mental Illnesses

Within the broad scope of mental health, many disorders can be diagnosed by the primary care
practitioner (Slavney, 1998) and in many cases treated effectively, with or without the assistance of a
therapist or counselor or support group. This is particularly so in relation to the depression and anxiety
that are the natural and understandable accompaniments of life on the streets. Health care projects can
also expand their clients' access to therapy by linking with other agencies that offer specialized
counseling, including rape crisis services, domestic violence programs, and programs for veterans.

The treatment of major mental illnesses in adults requires expertise that in general can only be provided
by a team of professionals including a psychiatrist. Illnesses in this category include major affective
disorders, including recurrent major depression and bipolar disorder, schizophrenia and related paranoid
disorders, severe personality disorders and dementia. Nevertheless in some situations primary care
practitioners may find themselves where psychiatric consultation is not available, or a patient is
unwilling to accept a referral. There may be no local community mental health centers or they may not
be responsive to the needs of homeless people. In this situation the clinician should be able to provide at
least basic pharmacological treatment for a mental illness and possibly enlist the assistance of a social
worker or other colleagues or agencies to attempt to address some of the person's other needs.

Psychiatric specialists may also be called upon to assist in diagnosing disorders associated with physical
illness, although the primary treatment responsibility remains with the general physician (e.g., delirium
associated with liver failure) (Slavney, 1998). It is important, therefore, that primary care practitioners
have the needed knowledge and skill to make this diagnostic distinction and have access to psychiatric
consultation when needed.

Services for homeless people with serious mental illnesses are distinct from psychiatric services for other
low-income people in that they have two principal goals: remission of the illness and resolution of the
person's homelessness. Services for homeless people are also distinctive in that they must take into
account the patients' transience, the hardship of their living circumstances, their distrust of formal
service systems, their lack of effective social supports, and their extreme poverty (Fischer, Colson &
Susser, 1996).

National Symposium on Homelessness Research 8-25

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Essential Elements of a Responsive Service System. The Federal Task Force on Homelessness and
Severe Mental Illness, in a 1992 report, Outcasts on Main Street (Federal Task Force on Homelessness,
1992), recommended the following essential elements of a system that would be responsive to homeless
people with severe mental illness:

Assertive outreach

Integrated care management

Safe Havens

Housing

Alcohol and/or other drug abuse treatment

Health care

Income support and benefits

Rehabilitation, vocational training, and employment assistance

Consumer and family involvement

Legal protections

In each area, clinicians and other professionals working with homeless people must team together
through alliances, cooperative agreements and coalitions to provide the array of services in the form best
suited for their local situation, culture and available resources.

Treatment Process. There are four principal stages in providing psychiatric services for homeless people
(Breakey and Thompson, 1997):

Engagement. Homeless mentally ill people often do not want the treatment that they badly need.
Primary care practitioners, shelter workers and others may have vital roles in gently persuading patients
to accept help. Outreach teams are vital. They may either work to motivate the person to come in to a
treatment center, or may bring the treatment resources to the homeless person "on the street.". Outreach
workers go to shelters and soup kitchens, to the streets and alleys, parks and railroad stations (Susser,
Valencia & Goldfinger, 1992). In some cases outreach may be life saving, where individuals risk death
or injury through exposure. The process of engagement, however, is often slow and outreach workers
must be prepared to devote many hours over many weeks or months on occasion, using much creativity,
to establish trust and rapport. Outreach is an ideal staff role for formerly homeless people, whose
knowledge of the territory and ability to establish rapport with homeless people is frequently superior to
that of most professionals (Van Tosh, 1993).

Basic Service Provision. Shelter, food, income support, clothing, and general health care will be needed
in most cases, in addition to whatever psychiatric treatment may be indicated. It is unrealistic to expect
homeless people to participate in treatment programs until their basic survival needs have been met.
Coordinating the various social and health agencies is frequently a major problem; case management has
come to be the major strategy employed. (Billig & Levinson, 1987; Goering & Wasylenki, 1996;
Swayze, 1992).

Clinical mental health services needed for homeless people cover the full range of services generally
provided by a community mental health center: diagnosis and evaluation, pharmacological and
psychotherapeutic treatments, and linkage to inpatient services when needed. Treatment teams need to
have the skills necessary to understand and treat some of the most difficult cases they are likely to
encounter in clinical practice. Empathic approaches are needed to gain the cooperation of people who
may have had bad experiences with treatment or its side-effects in the past, as is respect for the
individuality and integrity of each person.

8-26 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Sophistication in psychopharmacology is essential. Homeless people may be more intolerant of side-
effects of medications than many other patients. Drowsiness, neuromuscular abnormalities or diminished
alertness may expose a person to increased risk of victimization. A psychiatrist must be careful to avoid
such problems for patients while getting maximum therapeutic benefit. Effective medications with
potential for hazardous side effects may have to be avoided if patients are not able to have blood tests at
regular intervals. Oral medications may be lost, so that long-acting injectable preparations are preferable
where feasible. Some medications with street resale value will have to be avoided. In some cases
arrangements can be made for shelter staff or others to act as custodians of a person's medications.

Transition and Integration. Community mental health programs understand that their patients with
severe and persistent mental illnesses in all probability will require treatment for life. On the other hand,
programs for homeless people can not, by definition, provide indefinite care for people. Once a person
has been engaged, and basic service needs met, he or she must be moved into the mainstream mental
health service system. Homeless health care programs should work at developing collaborative
professional relationships and establishing linkages to community mental health programs in their areas.
There are many instances where the homeless health care program, with its special expertise, can be of
assistance to staff of the mental health center, just as there are instances where the homeless program
staff will look to the mental health center for long term support and treatment of their clients. To
facilitate transition the therapist in the homeless program may continue to work with the person after they
become settled in a home. A special model for this approach has been described "Critical Time
Intervention" (Susser et al., 1997).

Transitioning care into the mainstream system may prove extremely difficult or impossible in some cases
or situations, creating a dilemma for the homeless program. Either the mainstream system may not be
receptive, or the patient may not want to make the transition from a clinical situation he or she feels
comfortable with, to one that is unknown. In the latter case, the clinical team must work though this
difficulty with the patient explicitly, perhaps emphasizing the fact that other people may need to have
access to the benefits he or she has enjoyed. Where the mainstream system is unreceptive, the only
solutions are personal bridge-building and political advocacy at whatever level is necessary to compel the
system to respond to the needs of all citizens.

Housing Stabilization. Treatment of severe mental illness is difficult or impossible until the person has
some measure of stability in his or her housing. Initially, some type of emergency shelter must be found
until resources are obtained to provide a transitional housing arrangement and, in due course, more
permanent housing. Many individuals with severe psychiatric disabilities need much support in coping
with even the simple tasks of everyday living, so supervision and case management support will be
needed. Some emergency shelters are able to provide this level of support. Supervised group homes may
be of value for some clients, but many are solitary individuals who prefer to be on their own. Single
room occupancy (SRO) hotels may be ideal for such people, provided that they meet acceptable
standards and provide needed support services. Safe Havens provide safe environments and basic needs
with low demand on adherence to rules or participation in treatment (Federal Task Force, 1992). The
Department of Housing and Urban Development's Section 8 housing subsidies have been demonstrated
to increase the likelihood that mentally ill formerly homeless people will remain housed (Hough et al.,
1997). Another HUD program, Shelter Plus Care, provides housing subsidies linked to treatment and
case management.

Service Integration. The treatment process described above requires that patients have access to a full
range of treatment, rehabilitative and support services, including needs assessment, diagnosis and

National Symposium on Homelessness Research 8-27

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

treatment planning, medication management, counseling and supportive therapy, hospitalization and
inpatient care, 24-hour crisis-response services, rehabilitation and social skills training, income support,
housing and case management. Categorical federal and other governmental funding, as well as the
structure of human service organizations at the local level, have long been the source of service
fragmentation which interferes with the smooth and coordinated provision of this complex array of
services. A series of recent initiatives have therefore focused on the provision of comprehensive
services. Beginning in the early 1990s, the Center for Mental Health Services (Substance Abuse and
Mental Health Services Administration) funded the Projects for Assistance in Transition from
Homelessness (PATH) Program, which has been successful in providing outreach and case management
to homeless mentally ill individuals. To test a variety of services integration strategies, the Center for
Mental Health Services subsequently awarded ACCESS (Access to Community Care and Effective
Services and Supports) grants to nine states. These strategies range from an innovative voucher system
to co-location of services, cross-training of staff, and the use of interagency, multidisciplinary treatment
(Calloway & Morrisey, 1998; Randolph et al., 1997; Rosenheck et al., 1998).

At the clinical level, the use of interdisciplinary teams to provide coordinated care is best exemplified by
the Assertive Community Treatment (ACT) model, which has been extensively evaluated and found
effective for domiciled individuals with serious and persistent mental illnesses (Burns and Santos, 1995;
Olfson, 1990; Primm, 1996). This approach has also been found effective for work with homeless
people. Mobile teams consisting of clinicians, case managers and advocates, accessible to patients 24
hours per day and 7 days per week provide long term care and are prepared to work with the person in
whatever is the most appropriate setting (Dixon et al.,1997; Lehman et al., 1997)

The National Institute for Mental Health and the Center for Mental Health Services sponsored a series of
research demonstration projects in five cities in the 1990s. This series of experiments tested a variety of
strategies for case management, transition out of shelters, rehabilitation and housing integration, and
demonstrated that with appropriate methods, such as those listed above, 80 percent of seriously mentally
ill homeless people can be assisted to remain satisfactorily housed in the community (Shern et al., 1997;
Thompson and Breakey, 1997).

Special Services for Homeless People with Dual Diagnoses

People who suffer both from a major mental illness and a substance use disorder pose major challenges
to developing services that will successfully address both types of disorder. Their treatment is
particularly problematic because of the historic separation between addiction and mental health services,
which extends as far as the federal agencies concerned. Bringing together resources and treatment
philosophies in the service of a particular patient has proved difficult, but the current professional
opinion is that integrated treatment and rehabilitation approaches are most effective and model treatment
programs provide substance abuse and mental illness treatment simultaneously (Minkoff & Drake, 1991).

In homeless persons, the prevalence of substance use disorders in mentally ill persons is at least as high
as in those without mental illnesses. Estimates are fairly consistent that between 10 percent and 25
percent of homeless people have dual diagnoses (Breakey et al., 1989, Koegel & Burnam,1988; Tessler
& Dennis, 1989).

The Center for Mental Health Services and the Center for Substance Abuse Treatment sponsored a
Collaborative Demonstration Program at 16 sites for services for dually diagnosed homeless people. The
report of this program defines five critical client characteristics that influence program design:

8-28 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

• Disaffiliation;

• Multiple, complex needs;

• Impoverished environments;

• Effects of illness and addiction; and

• Low motivation for change/low self-esteem.

Major interventions employed by the 19 programs were similar to those that have been employed for
other homeless subgroups: outreach, case management, detoxification, day treatment, residential
treatment and system- wide coordination.

The initiative clearly established the importance of collaboration between professionals in the substance
abuse and mental illness fields to provide integrated services for this particularly vulnerable group who
constitute a significant segment of the homeless population (Winarski & Dubus, 1996). Ideally treatment
for substance abuse and mental illness should be provided simultaneously in the same facility. Where
this is not possible, close referral agreements should be established so that the maximum level of
coordination can be attained.

Conclusion

Despite the tremendous amount of knowledge and experience that has been gained over the past decade
in adapting clinical practice to the needs of homeless people, there is still much to be learned, as well as
numerous threats that challenge the successful continuation of this work. Recommendations to address
research and policy that will strengthen our knowledge and diminish the threats follow:

Continue to Support Increased Funding for Integrated Health Programs

Advances have been made in primary care, mental health and substance abuse services for homeless
people, only to be set back by the inability to maintain effective models. Demonstration projects need
the option of ongoing funding, if the program proves to be successful. Funding is also needed to expand
into areas now recognized as vital for improving and maintaining health, such as dental services, respite
care during convalescence, and integration of housing into mental health and substance abuse programs.
This is especially relevant in an environment of increasing need and decreased capacity to meet that need
(O'Connell, Lozier and Gingles, 1997).

Work For Universal Health Care Coverage to Eliminate the Negative Impact of Market
Influences on Delivery of Health Care

The rush by many health care organizations to stay afloat by increasing Medicaid revenue has resulted in
loss of access to services for uninsured homeless people. Even for those who do have insurance,
conversion of Medicaid to a managed care system has made access more problematic. It is interesting to
note in the discussion of clinical treatment above that the recommendations frequently include a lower
threshold for initiating treatment or hospitalization, necessity of frequent follow-up visits (sometimes
daily), use of alternative medications which may be more expensive (e.g., once-daily dosing), divergence
from strict protocols, flexibility in service location and easy access to a wide range of integrated services,
including specialty care. In other words, the kinds of adaptations to clinical care needed by homeless
people are in many cases the very practices that managed care discourages. Wunsch (1998) summarizes
the challenges of involving homeless people in managed care:

National Symposium on Homelessness Research 8-29

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

• The social circumstances of homeless people are often not compatible with the tightly controlled
access to health care that characterizes managed care.

• The health status of homeless people is markedly inferior to that of traditional managed care
enrollees, and is characterized by complex, interrelated conditions, including non-medical factors not
usually addressed by managed care entities (MCEs).

Develop a Federally-Funded Substance Abuse Program Targeted to Homeless People

As a society, we continue to deny the vast extent of the pathology and social dislocation attributable to
alcohol and drugs (Wilhite, 1992). The impact of substance abuse in causing and perpetuating
homelessness cannot be adequately addressed without significant additional resources. Existing
community resources are not sufficient — and often not appropriate — to meet the needs of homeless
people with substance abuse disorders, especially those with co-occurring mental illness.

Develop Effective Methodologies to Collect and Analyze Cost and Outcome Data.

Data on health care utilization, cost and outcomes have not been collected and analyzed for homeless
people as a group, undermining the ability of states to effectively serve them through managed care
arrangements (Wunsch, 1998). There is a consensus in the field that more information is needed on costs
of caring for homeless people, as well as which practices result in the best outcomes for which types of
people who are homeless. The BPHC initiative on outcomes mentioned earlier is one potential source for
developing approaches to measuring outcomes (U.S. Department of Human Services, 1996). Although
little has been done in the difficult arena of accurately determining costs of care, there is evidence of the
cost of not providing the care that results in expensive hospitalization (Salit et al., 1998).

Improve Dissemination to the Field of Results of Research and Practice

Additional research will not be useful without better strategies for incorporating research findings into
actual practice in the field. Health care is a rapidly changing and evolving field, with new technologies,
medications and treatment approaches being developed constantly. Not only do new practices need to be
tested for relevance with people who are homeless, mechanisms need to be developed to assure that
homeless health practitioners receive that information in a format that is useful and practical, including a
method to provide feedback and engage in ongoing dialogue with researchers.

Increase Training for Recruitment and Retention of Skilled Practitioners

Committed practitioners who are skilled in working with homeless people and willing to accept the
difficulties of the work are scarce. There is a need to continue training for providers already in the
field — both to continually improve quality and stay abreast of current practices, as well as to enhance
retention by preventing burnout. New practitioners also need to be trained. The reform in medical
education toward a more humanistic primary care model will hopefully result in the creation of a cadre of
medical providers who are trained to care for vulnerable populations such as people without homes.

More mental health professionals are also needed in health care programs treating homeless persons.
Their training should include placement in community-based health programs so that they can learn to
work hand-in-hand with generalist physicians in treating the intertwined physical and mental health
problems of homeless people. Since a great deal of care is also provided to homeless people in
emergency rooms, all medical and surgical trainees in medical school, residency, and fellowship

8-30 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless Peopie

programs must be trained to develop an appreciation for their patients' housing and poverty status, and
victimization history.

Unless they are resolved, all of the above factors — inadequate funding to fully implement the integrated
approach to homeless health care, impact of market-driven managed care, lack of funding for accessible
and appropriate substance abuse treatment, limited cost and outcome data, the disconnect between
research and practice, and the scarcity of skilled practitioners willing to serve this population — threaten
the survival of the unique integrated approach to care that has evolved to treat the health of homeless
people. Until such time as there is universal health care coverage and adequate housing for all, people
experiencing homelessness will need access to a health care system designed specifically to respond to
their unique needs.

National Symposium on Homelessness Research 8-31

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

References

Aber, J. L., Bennett, N. G., Conley, D. C. & Li, J. (1997). The Effects of Poverty on Child Health and
Development. Annual Review of Public Health, 78:463-83.

Aday, L. A. (1993). At Risk in America: The Health and Health Care Needs of Vulnerable Populations
in the United States. San Francisco: Jossey-Bass Inc.

Alperstein, G., Rappaport, C. & Flanigan, J. M. (1988). Health Problems of Homeless Children in New
York City. American Journal of Public Health, 78: 1232-1233.

Alstrom, C. H., Lindelius, R. & Salum, I. (1975). Mortality Among Homeless Men. British Journal of
Addiction, 70: 245-252.

Argeriou, M. & McCarty, D. (Eds.). (1990). Treating Alcoholism and Drug Abuse among Homeless
Men and Women: Nine Community Demonstration Grants. Alcoholism Treatment Quarterly, 7: 1.

Ball, F. J., & Havassy, B. E. (1984). A Survey of the Problems and Needs of Homeless Consumers of
Acute Psychiatric Services. Hospital & Community Psychiatry, 35, 917-921.

Bangsberg, D., Tulsky, J. P., Hecht, F. M. & Moss, A. R. (1997). Protease Inhibitors in the Homeless.
Journal of the American Medical Association, 278: 63-65.

Bassuk, E. L. & Rosenberg, L. (1988). Why Does Family Homelessness Occur? A Case-Control Study.
American Journal of Public Health, 78(7): 783-788.

Bassuk, E. L., Melnick, S. & Browne, A. (1998). Responding to the Needs of Low-Income and
Homeless Women Who Are Survivors of Family Violence. Journal of the American Medical Women's
Association, 53: 57-64.

Bassuk, E. L., Rubin, L. & Lauriat, A. S. (1984). Is Homelessness a Mental Health Problem? American
Journal of Psychiatry 141: 1546-1550.

Bassuk, E. L., Rubin, L. & Lauriat, A. S. (1986). Characteristics of Homeless Sheltered Families.
American Journal of Public Health 76: 1097-1 101.

Baxter, E. & Hopper, K. (1981). Private Lives/Public Spaces: Homeless Adults on the Streets of New
York. New York: Institute for Social Welfare Research.

Bernardo, J. (1985). Drug-Resistant Tuberculosis among the Homeless: Boston. Morbidity and
Mortality Weekly Report, 34: 429-431.

Billig, N. & Levinson, C. (1987). Homelessness and Case Management in Montgomery County,
Maryland: A Focus on Chronic Mental Illness. Psychosocial Rehabilitation Journal, 11: 59-66.

Blakeney, B. (1991). Old, Homeless and Sick. Geriatric Nursing, 12:220-2. Sept.-Oct.

Breakey, W. R. & Thompson, J. W. (1997). Psychiatric Services for Homeless People. In W. R.
Breakey & J. W. Thompson (Eds.) Mentally 111 and Homeless: Special Programs for Special Needs.
Amsterdam: Harwood Academic Publishers.

8-32 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Breakey, W. R., Susser, E. & Timms, P. (1992). Services for the Homeless Mentally 111. In G.
Thornicroft, C. R. Brewin & J. Wing (Eds.) Measuring Mental Health Needs. London: Gaskell.

Brickner, P. W., Filardo, T., Iseman, M., Green, B., Conanan, B. & Elvy, A. (1984). Medical Aspects of
Homelessness. Department of Community Medicine, St. Vincent's Hospital and Medical Center of New
York.

Brickner, P. W., Scharer, L. K., Conanan, B., Elvy, A. & Savarese, M. (Eds.). (1985). Health Care of
Homeless People. New York: Springer Publishing Company.

Brickner, P. W., Scharer, L. K., Conanan, B., Elvy, A., Savarese, M. & Scanlan, B. C. (Eds.) (1990).
Under the Safety Net: The Health and Social Welfare of the Homeless in the United States. New York:
W. W. Norton & Company.

Brooks-Gunn, J. & Duncan, G. J. (1997). The Effects of Poverty on Children. Future Child 7. 55-1 \.

Browne, A. & Bassuk, S. S. (1997). Intimate Violence in the Lives of Homeless and Poor Housed
Women: Prevalence and Patterns in an Ethnically Diverse Sample. American Journal of Orthopsychiatry
67: 261-278.

Brudney, K. & Dobkin, J. (1991). Resurgent Tuberculosis in New York City. American Review of
Respiratory Disease 144: 745-749.

Burnam, M. A. & Koegel, P. (1989). The Course of Homelessness Among the Seriously Mentally III: An
NIMH-Funded Proposal. Rockville: NIMH.

Burness Gleicher H., Carney, K., [Savarese] Feliciano, M., Kennedy, A. (1990). Staff Organization,
Retention, & Burnout. In Brickner, P.W. et al. (Eds.) Under the Safety Net: The Health Social Welfare
of the Homeless in the U. S. New York: W.W. Norton.

Burns, B. J. & Santos, A. B. (1995). Assertive Community Treatment: An Update of Randomized
Trials. Psychiatric Services 46(1): 669-675.

Burroughs, J., Bouma, P., O'Connor, E., & Smith D. (1990). Health Concerns of Homeless Women. In
Brickner, P.W. et al. (Eds.) Under the Safety Net: The Health and Social Welfare of the Homeless in the
United States. New York: W.W. Norton.

Burt, M. R. & Cohen, B. E. (1989). America's Homeless: Numbers, Characteristics, and the Programs
that Serve Them. Washington, DC: Urban Institute Press.

Busen, N. H. & Beech, B. (1997). A Collaborative Model for Community-Based Health Care Screening
of Homeless Adolescents. Journal of Professional Nursing 13(5): 316-324.

National Symposium on Homelessness Research 8-33

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Calloway, M., Morrisey, J. (1998). Overcoming Service Barriers for Homeless Persons With Serious
Psychiatric Disorders. Psychiatric Services 49(12): 1568-1572.

Caminero, J. A., Pavon, J. M., Rodriguez de Castro, F., Diaz, F., Julia, G., Cayla, J. A. & Cabrera, P.
(1996). Evaluations of a Directly Observed Six Months Fully Intermittent Treatment Regimen for
Tuberculosis In-Patients Suspected of Poor Compliance. Thorax 1(11): 1130-1133. November.

CASSP Technical Assistance Center. Developing Cultural Competence. Toward a Culturally
Competent System of Care, 1. Washington, DC: Georgetown University Child Development Center.

CDC. (1995). Screening for Tuberculosis and Tuberculosis Infection in High-Risk Populations.
Recommendations of the Advisory Council for the Elimination of Tuberculosis. Morbidity and Mortality
Weekly Report (MMWR) 44: 19-34.

CDC. (1998). Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and
HCV-related Chronic Disease. Morbidity and Mortality Weekly Report (MMWR) 47: 1-33.

Chaulk, P., Moore-Rice, K., Rizz, R. & Chaisson, R. (1995). Eleven years of community-based directly
observed therapy for tuberculosis. Journal of the American Medical Association 274(12): 945-951.
September.

Chavkin, W., Kristal, A., Seabron, C. & Guigli, P. (1987). The Reproductive Experience of Women
Living in Hotels for the Homeless in New York City. New York State Journal of Medicine 86: 10-13.

Cohen, C, Teresi, J. & Holmes, D. (1988) The Physical Well-Being of Old Homeless Men. Journal of
Gerontology 43: 121-128.

Conrad, K. J., Hultman, C. I. & Lyons, J. S. (Eds.). (1993). Treatment of Chemically Dependent
Homeless: Theory and Implementation in Fourteen American Projects. Alcoholism Treatment Quarterly
10:3/4.

Cousineau, M. R., Wittenberg, E. & Pollatsek, J. (1995). A Study of the Health Care for the Homeless
Program: Final Report. Bethesda, MD: Bureau of Primary Care, Health Resources and Services
Administration, Department of Health and Human Services.

Dixon, L., Kernan, E., Krauss, N., Lehman, A. & DeForge, B. (1997). Assertive Community Treatment
for Homeless Adults. In Breakey, W.R. & Thompson, J.W. (Eds. ) Mentally III and Homeless: Special
Programs for Special Needs. Amsterdam: Harwood Academic Publishers.

Eddins, E. (1993). Characteristics, Health Status and Service Needs of Sheltered Homeless Families.
Association of Black Nursing Faculty Journal, 4: 40-44.

Ewing, J. A. (1996). Detecting Alcoholism: The CAGE Questionnaire. Journal of the American
Medical Association 252: 1905-1907.

Farr, R. K., Koegel, P. & Burnam, A. (1986). A Study of Homelessness and Mental Illness in the Skid
Row Area of Los Angeles. Los Angeles: Los Angeles Department of Mental Health.

8-34 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Fierman, A. H., Dreyer, B. P., Quinn, L., Shulman, S., Courtlandt, C. D. & Guzzo, R. (1991). Growth
Delay in Homeless Children. Pediatrics 88: 918-925.

Filardo, T. (1985). Chronic Disease Management in the Homeless. In P. W. Brickner, L. K. Scharer, B.
Conanan, A. Elvy & M. Savarese (Eds.) Health Care of Homeless People. New York: Springer
Publishing Company.

Fischer, P. J. & Breakey, W. R. (1991). The Epidemiology of Alcohol, Drug and Mental Disorders
Among Homeless Persons. American Psychologist 46: 1115-1128.

Fischer, P. J., Colson & Susser, E. (1996). Homelessness and Mental Health Services. In Breakey, W.
R. (Ed.) Integrated Mental Health Services: Modern Community Psychiatry. New York: Oxford
University Press.

Fischer, P. J., Shapiro, S. & Breakey, W. R. (1986). Mental Health and Social Characteristics of the
Homeless. American Journal of Public Health 76: 519-524.

Fleischman, S. & Farnham, T. (1992). Chronic Disease in the Homeless. In Wood, D. (Ed.), Delivering
Health Care to Homeless Persons. New York: Springer Publishing Company.

Fors, S. W. & Jarvis, S. (1995). Evaluation of a Peer-Led Drug Abuse Risk Reduction Project for
Runaway/Homeless Youths. Journal of Drug Education, 25(4): 321-333.

Gelberg, L. & Linn, L. S. (1985). Health of Homeless Adults. Unpublished.

Gelberg, L. & Linn, L. S. (1989). Assessing the Physical Health of Homeless Adults. Journal of the
American Medical Association 262: 1973-1979.

Gelberg, L. & Linn, L. S. (1998). Social and Physical Health of Homeless Adults Previously Treated for
Mental Health Problems. Hospital and Community Psychiatry 39: 510-516.

Gelberg, L., Gallagher, T. C, Andersen, R. M. & Koegel, P. (1997). Competing Priorities As a Barrier
to Medical Care Among Homeless Adults in Los Angeles. American Journal of Public Health 87(2):
217-220.

Gelberg, L., Linn, L. S. & Mayer-Oakes, S. A. (1990). Differences in Health Status Between Older and
Younger Homeless Adults. Journal of American Geriatrics Society 38: 1220-1229.

Gelberg, L., Linn, L. S. & Rosenberg, D. J. (1988). Dental Health of Homeless Adults. Special Care in
Dentistry 8: 167-172.

Gelberg, L., Panarites, C. J., Morgenstern, H., Leake, B., Andersen, R. M. & Koegel, P. (1997).
Tuberculosis Skin Testing Among Homeless Adults. Journal of General Internal Medicine 12: 25-33.

Goering, P. N. & Wasylenki, D. (1996). Case Management. In Breakey, W.R. (EdJ Integrated Mental
Health Services: Modern Community Psychiatry. New York: Oxford University Press.

National Symposium on Homelessness Research 8-35

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Goetcheus, J., Gleason, M., Sarson, D., Bennett, T. & Wolfe, P. (1990). Convalescence for Those
without a Home: Developing Respite Services in Protected Environments. In Brickner, P.W. (Ed.) et al.,
Under the Safety Net: The Health and Social Welfare of the Homeless in the U. S. New York: W.W.
Norton.

Goodman, L. A. (1991). The Prevalence of Abuse in the Lives of Homeless and Housed Poor Mothers:
A Comparison Study. American Journal of Orthopsychiatry, 16: 489-500.

Goodman, L., Rosenberg, S., Mueser, K. & Drake, R. (1997). Physical and Sexual Assault History in
Women with Serious Mental Illness: Prevalence, Correlates, Treatment and Future Research Directions.
Schizophrenia Bulletin 23(4): 685-696.

Hagen, J. L. (1987). Gender and Homelessness. Social Wo rk: 312-316. July-August.

Hanzlick, R. & Parrish, R. (1993). Death Among the Homeless in Fulton County, Georgia, 1988-1990.
Public Health Reports 108: 488-491.

Harris, M. & Landis, C. L. (1997). New Directions in Therapeutic Intervention: Volume 2. Sexual
Abuse in the Lives of Women Diagnosed with Serious Mental Illness. Amsterdam, the Netherlands:
Harrowed Academic Publishers.

Hayward, R., Shapiro, M., Freeman, H. & Corey, C. (1988). Who Gets Screened for Cervical and Breast
Cancer? Results From a New National Survey. Archives of Internal Medicine 148: 1 177-1 181 .

HCH Clinicians' Network. (1999). Chronic Hepatitis C: Silent Intruder, Insidious Threat. Healing
Hands 3(2). March.

HCH Network. (1998). HCHN Service Continuum. Seattle, WA: Seattle/King County Department of
Public Health, (unpublished).

Hough, R. L., Harmon, S., Tarke, H., et al. (1997). Supported Independent Housing: Implementation
Issues and Solutions in the San Diego Project. In Breakey, W.R. & Thompson, J.W. (Eds.) Mentally III
and Homeless: Special Programs for Special Needs, 95-1 18. Amsterdam: Harwood Academic
Publishers.

Institute of Medicine. (1988). Homelessness, Health, and Human Needs. Washington, D.C.: National
Academy Press.

Interagency Council on the Homeless. (1994). Priority: Home! The Federal Plan to Break the Cycle of
Homelessness. Washington, DC: U. S. Department of Housing and Urban Development HUD- 1454-
CPD.

Jahiel, R. I. (1992). Health and Health Care of Homeless People. In Robertson, M. & Greenblatt, M.
(Eds.), Homelesssness: A National Perspective. New York: Plenum Press.

8-36 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Kern, G., Frisch-Niggemeyer, W., Wewalka, G., Bruns, C. (1986). Hepatitis a Outbreak in a Shelter for
the Homeless in Vienna. Wiener Klinische Wochenschrift 95(14): 457-461 .

Killion, CM. (1995). Special Health Care Needs of Homeless Pregnant Women. Advances in Nursing
Science 18(2): 44-56.

Kipke, M. D., Montgomery, S. B., Simon, T. R., & Iverson, E. F. (1997). Substance Abuse Disorders
Among Runaway and Homeless Youth. Substance Use Misuse 32(7-8): 969-986.

Kline, S., Hedemark, L., & Davis, S. (1995). Outbreak of Tuberculosis Among Regular Patrons of a
Neighborhood Bar. New England Journal of Medicine 333: 222-227.

Koegel P, Burnam M. A., Baumohl J. (1996). The Causes of Homelessness in Homelessness in America.
Ed. Jim Baumohl, New York, NY: Oryx Press.

Koegel, P. & Burnam, A. (1992). Problems in the Assessment of Mental Illness Among the Homeless.
In Robertson, M.J. & Greenblatt, M. (Eds.), Homelessness: A National Perspective. New York: Plenum
Press.

Koegel, P. & Gelberg, L. (1992). Patient-Oriented Approach to Providing Care to Homeless Persons. In
D. Wood, (Ed.) Delivering Health Care to Homeless Persons: A Guide to the Diagnosis and
Management of Medical and Mental Health Conditions. New York, NY: Springer Publishing Company.

Koegel, P., & Burnam, A. (1988). Alcoholism Among Homeless Adults in the Inner City of Los
Angeles. Archives of General Psychiatry 45: 1011-1018.

Koegel, P., Burnam, A. & Fair, R.K. (1988). The Prevalence of Specific Psychiatric Disorders Among
Homeless Individuals in the Inner City of Los Angeles. Archives of General Psychiatry 45: 1085-1092.

Ladner, S. (1992). The Elderly Homeless. In Robertson, M.J. & Greenblatt, M. (Eds.), Homelessness: A
National Perspective. New York: Plenum Press.

Lam, J. & Rosenheck, R. (1998). The Effect of Victimization on Clinical Outcomes of Homeless
Persons With Serious Mental Illness. Psychiatric Services 49(5): 678-683.

Lapham, S. C, Hall, M., Snyder, J., Skipper, B., McMurray-Avila, M., Pulvino, S. & Kozeny, T. (1996).
Demonstration of a Mixed Social/Medical Model Detoxification Program for Homeless Alcohol
Abusers. Contemporary Drug Problems 23, Summer.

National Symposium on Homelessness Research 8-37

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Link B., Phelan J., Bresnahan M., Stueve A., Moore R., & Susser E. (1995). Lifetime and Five- Year
Prevalence of Homelessness in the United States: New Evidence on an Old Debate. American Journal of
Orthopsychiatry 65(3): 347-354.

Long, H. L., Tulsky, J. P., Chambers, D. B., et al. (1998). Cancer Screening in Homeless Women:
Attitudes and Behaviors. Journal of Health Care for the Poor and Underserved 9: 276-292.

Mangura, B. T., Passannante, M. R. & Reichman, L. B. (1997). An Incentive in Tuberculosis Preventive
Therapy for an Inner City Population. International Journal of Tubercular Lung Disease, 1(6): 576-578,
December.

Marlatt, G. A., Somers, J. M. & Tapert, S. F. (1993). Harm Reduction: Application to Alcohol Abuse
Problems. NIDA Research Monograph, 137: 147-166.

Marlatt, G. A., Tucker, J. A., Donovan, D. M. & Vuchinich, R. E. (1997). Help-Seeking By Substance
Abusers: The Role of Harm Reduction and Behavioral -Economic Approaches to Facilitate Treatment
Entry and Retention. NIDA Research Monograph, 165: 44-84.

Mayo, K., White, S., Oates, S. K. & Franklin, F. (1996). Community Collaboration: Prevention and
Control of Tuberculosis in a Homeless Shelter. Public Health Nursing 13: 120-7, April.

McAdam, J., Brickner, P., Scharer, L., Crocco, J., & Duff, A. (1990). The Spectrum of Tuberculosis in a
New York City Men's Shelter Clinic (1982-1988). Chest 97: 798-805.

McMurray-Avila, M. (1997). Organizing Health Services for Homeless People. Nashville, TN:
National Health Care for the Homeless Council.

McNally, E. & Wood, J. (1992). Obstetrical Care and Family Planning for Homeless Women. In Wood,
D. (Ed.) Delivering Health Care to Homeless Persons. New York, NY: Springer Publishing Company.

Michael, M. & Brammer, S. (1988). Medical Treatment of Homeless Hypertensives. American Journal
of Public Health 78: 78-94.

Miller, D. & Lin, E. (1988). Children in Sheltered Homeless Families: Reported Health Status and Use
of Health Services. Pediatrics 81: 668-673.

Minkoff, K. & Drake, R. E. (Eds.) (1991). Dual Diagnosis of Major Mental Illness and Substance
Disorder. New Directions for Mental Health Services 50: 95-107. San Francisco: Jossey-Bass.

Morbidity and Mortality Weekly Report. (1991). Deaths Among Homeless Persons - San Francisco,
1985-1990. Morbidity and Mortality Weekly Report 40: 877-880.

Morbidity and Mortality Weekly Report. (1992). Deaths Among Homeless Persons - San Francisco.
Journal of the American Medical Association 267: 484-485.

Morey, M. A., Friedman, L. S. (1993). Health Care Needs of Homeless Adolescents. See
Comments - Current Opinion in Pediatrics 5(4): 395-399.

Morrow, R., Fanta, J. & Kerlen, S. (1997). Tuberculosis Screening and Anergy in a Homeless
Population. Journal of the American Board of Family Practitioners, 10: 1-5, Jan. -Feb.

8-38 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Morse, G. A. & Calsyn, R. J. (1986). The St. Louis Mentally Disturbed Homeless: Needy, Willing, But
Underserved. International Journal of Mental Health 14: 74-94.

Mowbray, C, Johnson, V., Solarz, A., Combs, C. (1986). Mental Health and Homelessness in Detroit:
A Research Study. Michigan Department of Mental Health.

Moy, J. & Sanchez, M. (1992). The Cutaneous Manifestations of Violence and Poverty. Archives of
Dermatology 128(6): 829-839.

National Health Care for the Homeless Council. (1994). Combating Tuberculosis and Homelessness:
Recommendations for Policy and Practice. Nashville: National HCH Council.

New York State Council on Children and Families. (1984). Meeting the Needs of Homeless Youth.
Albany, New York: Author.

NIAAA. (1991a). A Guide to Housing for Low-Income People Recovering from Alcohol and Other
Drug Problems. Washington, DC: NIAAA, January.

NIAAA. (1991b). Housing Initiatives for Homeless People with Alcohol and Other Drug Problems:
Proceedings of a National Conference - February 29-March 2, 1991 in San Diego. Washington, DC:
NIAAA, November.

North, C. & Smith, E. (1992). Posttraumatic Stress Disorder Among Homeless Men and Women.
Hospital and Community Psychiatry 43(10): 1010-1016.

North, C, Smith, E. & Spitznagel, E. (1994). Violence and the Homeless: An Epidemiologic Study of
Victimization and Aggression. Journal of Traumatic Stress 7(1): 95-1 10.

Nyamathi, A. (1992). Comparative Study of Factors Relating to HrV Risk Level of Black Homeless
Women. Journal of Acquired Immune Deficiency Syndromes 5: 222-228.

Nyamathi, A. (1993). Sense of Coherence in Minority Women At Risk for HrV Infection. Public Health
Nursing 10(3): 151-158.

O'Connell, J. J. & Groth, J. (Eds.) (1991). The Manual of Common Communicable Diseases in Shelters.
Boston: Boston HCH Program.

O'Connell, J. J., Lozier, J. & Gingles, K. (1997). Increased Demand and Decreased Capacity:
Challenges to the McKinney Act's Health Care for the Homeless Program. Nashville, TN: National
HCH Council, July.

O'Connell, J. J., Summerfield, J. & Kellogg, R. (1990) The Homeless Elderly. In Brickner, P.W. et al.,
(Eds.) Under the Safety Net: The Health and Social Welfare of the Homeless in the U. S. New York:
W.W. Norton.

O'Connell, J. & Lebow J. (1992). AIDS and the Homeless of Boston. New England Journal of Public
Policy 8: 541-556.

Olfson, M. (1990). Assertive Community Treatment: An Evaluation of the Experimental Evidence.
Hospital and Community Psychiatry 41: 635-641.

National Symposium on Homelessness Research 8-39

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Pablos-Mendez, A., Knirsch, C. A., Barr, R. G., Lerner, B. H. & Frieden, T. R. (1997). Nonadherence in
Tuberculosis Treatment: Predictors and Consequences in New York City. American Journal of
Medicine, 102(2): 164-170.

Padgett, D. & Struening, E. (1992). Victimization and Traumatic Injuries Among the Homeless:
Associations With Alcohol, Drug and Mental Problems. American Journal of Orthopsychiatry 62(4):
525-534.

Paterson, C. M. & Roderick, P. (1990). Obstetric Outcome in Homeless Women. British Medical
Journal. 301: 263-266.

Peterson, J., Pilote, L., Zolopa, A. & Moss, A. (1993). Insights From the Street: Peer Health Advisors
and Medical Care in the Homeless. International Conference on AIDS 9:869 (abstract no. PO-D16-
3909).

Pianteri, O., Vicic, W., Byrd, R., Brammer, S. & Michael, M. (1990). Hypertension Screening and
Treatment in the Homeless. In Brickner, P.W. et al., (Eds.) Under the Safety Net: The Health and Social
Welfare of the Homeless in the U S. New York: W.W. Norton.

Pilote, L., Tulsky, J. P., Zolopa, A. R., Hahn, J. A., Schecter, G. F. & Moss A. R. (1996). Tuberculosis
Prophylaxis in the Homeless. A Trial to Improve Adherence to Referral. Archives of Internal Medicine,
56: 161-5, Jan. 22.

Popli, S., Davirdas, J. T., Neubauer, B., Hochenberry, B. Hano, J. E. & Ing, T. S. (1986). Transdermal
Clonidine in Mild Hypertension. Archives of Internal Medicine 146: 2140-44.

Primm, A. B. (1996). Assertive Community Treatment. In Breakey, W.R. (Ed.) Integrated Mental
Health Services: Modern Community Psychiatry. New York: Oxford University Press.

Prochaska, J. O., DiClemente, C. C. & Norcross, J. C. (1992). In Search of How People Change:
Applications to Addictive Behaviors. American Psychologist 47(9): 1 102-1 1 12.

Randolph, F., Blasinsky, M., Leginski, W., Parker, L. B., Goldman, H. H. (1997). Creating Integrated
Service Systems for Homeless Persons with Mental Illness: The ACCESS Program. Psychiatric Services
48(3): 369-373.

Reuler, J., Bax, M. & Sampson, J. (1986). Physician House Call Services for Medically Needy, Inner-
City Residents. American Journal of Public Health 76: 1 131-1 134.

Rew L. (1996). Health Risks of Homeless Adolescents: Implications for Holistic Nursing. Journal of
Holistic Nursing, 14(4): 348-359, December.

Ringwalt, C. L., Greene, J. M., Robertson, M. & McPheeters, M. (1998). The Prevalence of
Homelessness Among Adolescents in the United States. American Journal of Public Health, 88(9):
1325-1329.

Robertson, M. & Cousineau, M. (1986). Health Status and Access to Health Services Among the Urban
Homeless. American Journal of Public Health 76: 561-563.

8-40 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Robertson, M. J. (1996). Homeless Youth on Their Own. Berkeley, California: Alcohol Research
Group.

Robertson, M., Ropers, R. & Boyer, R. (1985). The Homeless of Los Angeles County: An Empirical
Evaluation. Los Angeles: UCLA School of Public Health/Los Angeles Basic Shelter Research Project.

Robertson, M., Zlotnick, C. & Westerfelt, A. (1997). Drug Use Disorders and Treatment Contact
Among Homeless Adults in Alameda County, California. American Journal of Public Health 87: 221-
228.

Rosenheck, R., Morrissey, J., Lam, J., Calloway, M., Johnsen, M., Goldman, G., Calsyn, R., Teague, G.,
Randolph, F., Blasinsky, M., & Fontana, A. (1998). Service System Integration, Access to Services and
Housing Outcomes in a Program for Homeless People with Mental Illness. American Journal of Public
Health 88(11): 1610-1615.

Roth, D. & Bean, G. (1986). New Perspectives on Homelessness: Findings from a Statewide
Epidemiological Study. Hospital & Community Psychiatry 37:712-719.

Sacks, J., Phillips, J. & Cappelletty, G. (1987). Characteristics of the Homeless Mentally Disordered
Population in Fresno County. Community Mental Health Journal 23: 1 14-1 19.

Sakai, J., Kim. M., Shore, J. & Hepfer, M. (1998). The Risk of Purified Protein Derivative Positivity in
Homeless Men With Psychotic Symptoms. Southern Medical Journal 91: 345-348.

Salit, S. A., Kuhn, E. M., Hartz, A. J., Vu, J. M. & Mosso, A. L. (1998). Hospitalization Costs
Associated With Homelessness in New York City. New England Journal of Medicine 338(24), June 11.

Scanlan, B. C. & Brickner, P. W. (1990). Clinical Concerns in the Care of Homeless Persons. In
Brickner, P.W. et al., (Eds.) Under the Safety Net: The Health and Social Welfare of the Homeless in the
U. S. New York: W.W. Norton.

Schutt, R. K & Garrett, G. R. (1992). Responding to the Homeless: Policy and Practice. New York:
Plenum Press.

Segal, S. P., Gomory, T. & Silverman, C. J. (1998). Health Status of Homeless and Marginally Housed
Users of Mental Health Self-Help Agencies. Health & Social Work 23(1): 45-52, February.

Sherman, D.J. (1992). The Neglected Health Care Needs of Street Youth. Public Health Report 07:
433-40, July-Aug.

Shuler, P. A. (1991). Homeless Women's Holistic and Family Planning Needs: An Exposition and Test
of the Nurse Practitioner Model (Dissertation). Los Angeles: University of California, Los Angeles.

Shuler, P. A., Gelberg, L. & Davis, J. E. (1995). Characteristics Associated With the Risk of
Unintended Pregnancy Among Urban Homeless Women. Journal of the American Academy of Nurse
Practitioners 7: 13-32.

National Symposium on Homelessness Research 8-41

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Slavney, P. (1998). Psychiatric Dimensions of Medical Practice. Baltimore: Johns Hopkins University
Press.

Smereck , G. A. & Hockman, E. M. (1998). Prevalence of fflV Infection and HIV Risk Behaviors
Associated with Living Place: On-The-Street Homeless Drug Users as a Special Target Population for
Public Health Intervention. American Journal of Drug and Alcohol Abuse, 24(2): 299-319, May.

Smith, E. M., North, C. S. & Spitznagel, E. L. (1992). A Systematic Study of Mental Illness, Substance
Abuse and Treatment in 600 Homeless Men. Annals of Clinical Psychiatry 4: 1 1 1-120.

Smith, E. M., North, C. S. & Spitznagel, E. L. (1993). Alcohol, Drugs and Psychiatric Comorbidity
Among Homeless Women: An Epidemiological Study. Journal of Clinical Psychiatry 54: 82-87.

Somlai, A. M., Kelly, J. A., Wagstaff, D. A. & Whitson, D. P. (1998). Patterns, Predictors, and
Situational Contexts of HIV Risk Behaviors Among Homeless Men and Women. Soc Work 43(1): 7-20,
January.

Stahler, G.J. (1995). The Effectiveness of Social Interventions for Homeless Substance Abusers.
Journal of Addictive Diseases 14: 4.

Stark, L. (1992). Barriers to Health Care for Homeless People. In Jahiel, R. (Ed.) Homelessness: A
Prevention Oriented Approach. Baltimore: The Johns Hopkins University Press.

Stoner, M. (1983). The Plight of Homeless Women. Social Service Review 57: 565-581, December.

Stricof, R. L., Kennedy, J. T., Nattell, T. C, Weisfuse, I. B., & Novick, L. F. (1991). HW
Seropre valence in a Facility for Runaway and Homeless Adolescents. American Journal of Public
Health, 81 (supplement): 50-53.

Susser, E., Conover, S. & Struening, E. (1989). Problems of Epidemiological Method in Assessing the
Type and Extent of Mental Illness Among Homeless Adults. Hospital and Community Psychiatry 40:
261-265.

Susser, E., Struening, E. & Conover, S. (1989). Psychiatric Problems in Homeless Men. Archives of
General Psychiatry 46: 845-850.

Susser, E., Valencia, E. & Goldfinger, S.M. (1992). Clinical Care of Homeless Mentally 111 Individuals:
Strategies and Adaptations. In Lamb, H.R., Bachrach, L.L. & Kass, F.I.(Eds.): Treating the Homeless
Mentally 111. Washington, D.C.: American Psychiatric Association.

Susser, E., Valencia, E., and Conover, S. (1993). Prevalence of HrV Infection Among Psychiatric
Patients in a New York City Men's Shelter. American Journal of Public Health 83(4): 568-570.

Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W., & Wyatt, R.J. (1997). Preventing Recurrent
Homelessness Among Mentally 111 Men: A "Critical Time" Intervention After Discharge From A Shelter.
American Journal of Public Health 87(2): 256-262.

Swayze, F. V. (1992). Clinical Case Management with the Homeless Mentally 111. In Lamb, H. R.,
Bachrach, L.L. & Kass, F.I.(Eds.), Treating the Homeless Mentally 111. Washington, DC: American
Psychiatric Association.

8-42 National Symposium on Homelessness Research

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Tessler, R. & Dennis, D. (1989). A Synthesis of NIMH-Funded Research Concerning Persons Who are
Homeless and Mentally III. Washington, DC: U. S. Department of Health and Human Services.

Thompson, J. W. & Breakey, W. R. (1997). The Present and Future of Innovative Programs for the
Homeless Mentally HI. In Breakey, W.R. & Thompson, J.W. (eds.) Mentally III and Homeless: Special
Programs for Special Needs. Amsterdam: Harwood Academic Publishers.

Torres, R. A., Mani, S., Altholz, J. & Brickner, P. W. (1990). Human Immunodeficiency Virus Infection
Among Homeless Men in a New York City Shelter. Archives of Internal Medicine 150: 2030-2036.

Tsemberis, S. (1996). From Outcasts to Community: A Support Group for Homeless Men. In
Andronico, M.P. (Ed. ) Men in Groups. Washington, DC: American Psychological Association.

U. S. Department of Health and Human Services. (1996). The Working Group on Homeless Health
Outcomes: Meeting Proceedings. Washington, DC: HRSA/BPHC/DPSP/HCH Branch, June.

U. S. Department of Health and Human Services. (1998b). Health Care for the Homeless Outcome
Measures: A Chronicle of Twenty Pilot Studies. Washington, DC: HRSA/BPHC/DPSP/HCH Branch.

U. S. Department of Health and Human Services. (1998a). Health Care for the Homeless Directory.
Washington, DC: HRSA/BPHC/DPSP/HCH Branch.

Usatine, R. P., Gelberg, L., Smith, M. H. & Lesser, J. (1994). Health Care for the Homeless: A Family
Medicine Perspective. American Family Physician 49: 139-146.

Vicic, W. & Weber, C. (1992). Hypertension in Persons Who Are Homeless. New York, NY: St.
Vincent's Hospital, Department of Community Medicine.

Wang, E. E., King, S., Goldberg, E., Bock, B., Milner, R. & Read, S. (1991). Hepatitis B and Human
Immunodeficiency Virus Infection in Street Youths in Toronto, Canada. Pediatric Infectious Disease
Journal 10(2): 130-133.

Weinreb, L. (1992). Preventive Medical Care for Homeless Men and Women. In Wood, D. (Ed.)
Delivering Health Care to Homeless Persons: The Diagnosis and Management of Medical and Mental
Health Conditions. New York: Springer Publishing.

Weitzman, B. C. (1989). Pregnancy and Childbirth: Risk Factors for Homelessness? Family Planning
Personnel 27(4): 175-178, 1989.

Whitfield, C. L., Thompson, G., Lamb, A., Spencer, V., Pfeifer, M. & Browning-Ferrando, M. (1978).
Detoxification of 1,024 Alcoholic Patients Without Psychoactive Drugs. Journal of the American
Medical Association 239(14): 1409-1410.

National Symposium on Homelessness Research 8-43

Balancing Act: Clinical Practices that Respond to the Needs of Homeless People

Wilhite, J. (1992). Public Policy and the Homeless Alcoholic: Rethinking Our Priorities for Treatment
Programs. In Robertson, M. J. & Greenblatt, M. (eds.) Homelessness: A National Perspective. New
York: Plenum Press.

Williams, L. (1992). Addiction on the Streets: Substance Abuse and Homelessness in America.
Washington, DC: National Coalition for the Homeless.

Winarski, J. T. & Dubus, P. (1996). An Analysis of 16 Federally-Funded Programs for Homeless
Individuals with Co-occurring Mental Health and Substance Use Disorders. Newton Center, Mass.: The
Better Homes Fund.

Wittman, F. D. & Madden, P. (1988). Alcohol Recovery Programs for Homeless People: A Survey of
Current Programs in the U. S. Washington, DC: NIAAA, February.

Wood, D. (Ed.) (1992). Delivering Health Care to Homeless Persons: The Diagnosis and Management
of Medical and Mental Health Conditions. New York: Springer Publishing.

Wood, D., Valdez, R., Hayashi, T. & Shen, A. (1990). Health of Homeless Children and Housed, Poor
Children. Pediatrics 86(6): 858-866.

Wrenn, K. (1990). Foot Problems in Homeless Persons. Annals of Internal Medicine 113: 565-567.

Wright, J. D. (1990). The Health of Homeless People: Evidence From The National Health Care for The
Homeless Program. In Brickner, P.W. et al. (Eds. ) Under the Safety Net: The Health and Social Welfare
of the Homeless in the United States. New York: W.W. Norton.

Wright, J. D., & Weber, E. (1987). Homelessness and Health. New York: McGraw-Hill.

Wright, J., Rossi, P., Knight, J., Weber-Burdin, E., Tessler, R., Stewart, C, Geronimo, M. & Lam, J.
(1985). Health and Homelessness in New York City. Robert Wood Johnson Foundation.

Wunsch, D. (1998a). Can Managed Care Work for Homeless People? Guidance for State Medicaid
Programs. New York: Care for the Homeless and National HCH Council, October.

Wunsch, D. (1998b). Searching for the Right Fit: Homelessness and Medicaid Managed Care. New
York: Care for the Homeless and National HCH Council, October.

Zolopa, A., Hahn, J., Gorter, R., Miranda, J., Wlodarczyk, D., Peterson, J., Pilote, L. & Moss, A. (1994).
HTV and Tuberculosis Infection in San Francisco's Homeless Adults. Journal of the American Medical
Association 272(6): 455-461.

8-44 National Symposium on Homelessness Research

Emergency Shelter and Services:
Opening a Front Door to the Continuum of Care

Judith D. Feins, Ph.D.

Linda B. Fosburg, Ph.D.

Abstract

This paper describes the provision of emergency shelter and services to homeless persons in the United
States. Administered by the U.S. Department of Housing and Urban Development, the Emergency
Shelter Grant (ESG) Program has been helping States and localities provide facilities and services to
shelter homeless people but at the same time to aid in their transition from temporary shelter to
permanent homes. In large part, this paper grows out of an evaluation of the ESG Program, conducted in
1993, which provides the best description currently available of emergency shelters and homeless
services across the United States.

The paper also describes several variations on the ESG program. Many emergency shelters require that
clients participate in case management and services. A recent development is the provision of shelter
with more flexible requirements. Safe Havens provide a safe and decent alternative to the streets for
homeless persons with severe mental illness who need adjustment time before engaging in treatment and
other supportive services. Recent interviews conducted by Abt Associates with a range of other
emergency shelter organizations reveal that homeless shelters continue to respond to the needs of
homeless people by expanding their programs to include a wider spectrum of services. In addition to
describing the types of shelter programs found throughout the United States, this paper describes the
populations being served, identifies the effective practices in emergency shelter and services, and
comments on the future research needs.

Lessons for Practitioners, Policy Makers, and Researchers

• Shelter providers currently see their mission as opening a front door to the Continuum of Care, so
that their clients are started on a path toward stable independent living. 1

• Today's emergency shelters are much more than "three hots and a cot" — or three meals and a bed.
Nor are they a temporary stopgap. Instead, they are sources of a wide range of services for homeless
persons.

• This paper grows out of an evaluation of the Emergency Shelter Grant (ESG) Program. The ESG
funds may be used for the construction, rehabilitation, or conversion of buildings into homeless
shelters, shelter operating expenses and administrative costs, provision of essential services, and
homelessness prevention. ESG monies typically make up six to ten percent of shelter budgets.

• Families, which make up approximately one-third of the homeless population nationally, were the
most frequently cited population served by the ESG-funded providers.

1 In many cases.crossing the threshhold into an emergency shelter is one of many entryways that a homeless person may take into
the continuum of care.

National Symposium on Homelessness Research 9-1

Emergency Shelter Services: Opening a Front Door to Continuum of Care

• The four top sources of the referrals to shelters were social services agencies, clergy, friends, and
other shelters.

• The mean length of stay in these emergency shelters was 71 days (the median was 30 days).

• The joint provision of shelter and services has proven to be one of the most useful means of assisting
clients.

9-2 National Symposium on Homelessness Research

Emergency Shelter Services: Opening a Front Door to Continuum of Care

Introduction

This paper describes the provision of emergency shelter and services to homeless persons in the United
States. In general, emergency shelters for the homeless provide indoor space with beds and meals to
those who have no other place to stay. Common variations of emergency shelters include the night-only
shelter (which requires guests to be elsewhere during the day), the day-only shelter (which provides
daytime space, meals, and sanitary facilities but not overnight sleeping space), and 24-hour shelters
(which can be used by guests around the clock). Different types of shelters may serve different
populations. Shelters also vary greatly in size, from fewer than 10 beds to several hundred beds.

In large part, this paper grows out of an evaluation of the Emergency Shelter Grants (ESG) Program, a
Federal program that has been an important factor in expanding the quality and quantity of shelter and
services since 1986. 2 The ESG evaluation is a major source of quantitative data collected from a
representative national sample of emergency shelter providers in 1992. It provides the best description
currently available of emergency shelters and homeless services in the United States. 3 In addition, Abt
Associates recently interviewed a number of major homeless services providers to update the ESG
evaluation's findings. 4

Other sources of national data include HUD's 1988 National Survey of Shelters for the Homeless and an
earlier examination of related federal support for emergency food and shelter. Apart from these, research
on emergency shelters has primarily been descriptive, usually based on a single site; the results are
therefore not comparable to a national survey.

Providing Emergency Shelter

Since its inception, the focus of the Emergency Shelter Grants (ESG) program, administered by the U.S.
Department of Housing and Urban Development, has been helping States and localities provide facilities
and services to meet local needs, to shelter homeless people but at the same time to aid in their transition
from temporary shelter to permanent homes. The ESG program was established by Congress through the
Homeless Housing Act of 1986, to provide funds for emergency shelters and essential services for the
homeless. One year later, it was incorporated into the McKinney Act of 1987 and took its place among
an array of programs designed to address the plight of homeless men, women, and children in the United
States. It has been a core part of homeless assistance throughout the first decade.

Each year, HUD allocates ESG funding to supplement State, local, and private efforts to improve the
number and quality of emergency homeless shelters. The ESG funds may be used for the construction,
rehabilitation, or conversion of buildings into homeless shelters, as long as the local agency uses the
property as a homeless shelter for a specified time period. ESG grants also may be used for shelter
operating expenses and administrative costs.

2 See Judith D. Feins, Linda B. Fosburg, and Gretchen Locke, Evaluation of the Emergency Shelter Grants Program
(Washington, DC: U.S. Department of Housing and Urban Development, September 1994).

3 The 1996 National Survey of Homeless Assistance Providers and Clients, conducted by the Census Bureau and sponsored by

a dozen Federal agencies under the auspices of the Interagency Council on the Homeless, will provide a more current description.
However, its results have not been published yet.

These organizations included the Salvation Army, Catholic Charities of America, and the International Union of Gospel
Missions.

National Symposium on Homelessness Research 9-3

Emergency Shelter Services: Opening a Front Door to Continuum of Care

ESG funds are provided to States, territories, 5 and qualified cities and counties; the States must distribute
the funds to local governments or private nonprofit organizations. Local governments must match ESG
grants dollar-for-dollar from other sources after the first $100,000. They may administer the grants
themselves or distribute the funds to private nonprofit organizations.

Since 1987, ESG funding has helped provide shelter for many homeless persons in need of help. 6 A total
of $425.9 million in program funding was distributed nationwide through 1994. But ESG monies
typically made up 6 to 10 percent of shelter budgets; the shelters this program supported usually had
significant other funding sources. Among the most common other funding sources for emergency shelter
were HUD's Community Development Block Grant program and two McKinney programs. The Federal
Emergency Management Agency (FEMA) continues to administer the Emergency Food and Shelter
grants, 7 for which Congress appropriated $1,552.1 million between 1987 and 1998. In addition, the
Emergency Community Services program of the Department of Health and Human Services distributed
$220.4 million in funding from 1987 to 1995.

Supporting Homeless Services

Apart from assisting in the provision of physical shelter, the ESG program is an important source of
funds for essential services for homeless people. Essential services are related social services in areas
such as employment, health, drug abuse, and education. Essential services may be provided in a shelter
setting, or they may be offered by separate (non-shelter) provider organizations. When they are offered
the latter way, linkages must be made between shelter clients and the service providers. An example of a
non-shelter service provider is the Larkin Street Youth Center in San Francisco, a drop-in center for
youth aged 12 to 23 that operates 12 hours per day but (in 1992) did not operate a night shelter. Its broad
range of services includes case management, employment counseling, referral, and a fully equipped
medical center.

Among emergency shelters, day-only and 24-hour facilities tended to be the most services-rich. While
nearly three-quarters of night-only shelters offered seven or fewer services, almost two-thirds of day
shelters and over 40 percent of 24-hour facilities offer between twelve and nineteen services to their
clients. ESG funds directly supported a great deal of this service activity.

ESG funding is also used for homelessness prevention: to assist individuals and families at-risk of
homelessness in retaining their housing; and to help homeless clients obtain permanent housing.
Homelessness prevention is intended to reduce the flow of clients into shelters, as well as aiding those
ready to move into more stable living situations. An example of homelessness prevention is the
American Red Cross in the San Francisco area. The Bay Area chapter of the American Red Cross
coordinates the homelessness prevention allocations for 29 agencies serving the city's homeless. Their
coordination of the pool of funds for prevention ensures that the same criteria for receipt of funds are
applied across all agencies.

5 Beginning October 1 , 1998, Indian Tribes are no longer eligible for ESG funds. Instead, they may apply for the new Native
American Housing Block Grant.

6 Since 1995, grant amounts under ESG and several other HUD programs for the homeless have been combined into the
Homeless Assistance Grants (also administered by HUD).

7 The early implementation of the federal food and shelter programs is detailed in the U.S. General Accounting Office
publication Homelessness: Implementation of Food and Shelter Programs under the McKinney Act (Washington, DC, December

1987).

9-4 National Symposium on Homelessness Research

Emergency Shelter Services: Opening a Front Door to Continuum of Care

The ESG program evaluation showed substantial allocations to homelessness prevention; in the 12
months leading up to the study, ESG funds had aided almost 35,000 at-risk individuals and families to
retain their housing. However, there are other funding sources and other studies on this topic. It will be
addressed in another session of this symposium.

What Are the Program Types?
Shelters and Safe Havens

Of all the service providers that received Emergency Shelter Grant funds in 1991, 81.8 percent were
shelters, while the remainder were not. The shelters were either day-only facilities (5.6 percent), night-
only shelters (9.5 percent), or 24-hour operations (84.9 percent). Of the 24-hour programs, most were
open seven days a week.

Among the shelters receiving ESG funding, there were various types of facilities. Approximately 30
percent were dormitory-style shelters, and 47.7 percent were group homes. Smaller numbers of shelters
characterized themselves as scattered-single apartments, groups of apartments or apartment buildings,
rooms in single-room occupancy (SRO) facilities, or hotels or motels.

Staff sizes for shelter providers are shown in Exhibit 1 . Providers operating shelters reported a median of
six paid, full-time-equivalent staff and one unpaid (volunteer) staff person working in their organizations.
Staffing levels in local government shelters (a mean of 13.5) were similar to those in private nonprofit
shelters (a mean of 14.1).

Among non-shelter agencies (providing other services to homeless people), private nonprofits averaged
11.8 full-time staff members while local government agencies averaged just 4.5 staff members. The
staffs of these agencies averaged 2.0 unpaid volunteers. Thus, shelter staffs were slightly larger than the
staffs of non-shelter service providers, and they had larger numbers of volunteers.

National Symposium on Homelessness Research 9-5

s
3

v.
O
O
O

mm V

»o

^H V£>

■£5

i-H

CN ©

*->

«a c/3

o u

n-Pr
helte

r-H

Tf-

Tj- o

«fr

i-H

o4 t-3

J? 35

■*•»

S cfl

u fc«

ove
elte

V£>

CO O

rJ,

V5
(H

«*H

4-i

l-H

o»

• 1-H

•ih

•iH

•^

c«

■ H

4-)

d
•— i

U V

H
i

°P

<L>

a> at

s::

s r:

£^;

£S

C/5

re
a>
co
a>
tr

co
co

CD
C
CO

E
o

X
c
o

o
a.

c
o

Emergency Shelter Services: Opening a Front Door to Continuum of Care

The overall median number of beds for all shelters receiving ESG funds in 1992 was 26 beds, and the
mean was 50. Exhibit 2 shows that the number of beds varied across the different types of shelters.
Night-only shelters tended to be larger, with a median of 31.5 beds, while 24-hour shelters had a median
of 25 beds. Not surprisingly, day-only shelters had the smallest number of beds, with a median of 10.

Exhibits 3 and 4 show the number of beds in ESG-funded shelters in 1992, compared to the shelter bed
capacity estimated in HUD's 1988 National Survey of Shelters for the Homeless. 8 The -average bed
capacity was approximately the same. However, the proportion of ESG-funded shelters with fewer than
25 beds was slightly higher than the proportion of small shelters estimated by HUD (49 percent of ESG-
funded shelters compared to 44 percent in HUD's estimates). The total bed capacity of ESG-funded
shelters in 1992 was 108,735, with an average nightly total occupancy of 88,279. HUD's 1988 survey
estimated an average nightly occupancy of 1 80,000 in shelters nationwide. Even assuming some modest
increase in the number of available beds between 1988 and 1992, a substantial proportion of the nation's
shelter capacity was found in ESG-funded shelters.

A recent development in the provision of shelter services targets homeless persons with mental
disabilities. Safe Havens, funded initially as a component of HUD's Supportive Housing Program in
1994, had 80 funded projects by 1997 (National Resource Center for Homelessness and Mental Illness,
1997). Safe Havens provide a safe and decent alternative to the streets for homeless persons with severe
mental illness who need adjustment time before engaging in treatment and other supportive services.
These programs are designed as transitional residences, with no specific time limits and low-demands to
participate in mental health or substance abuse treatment programs or to receive other supportive
services. 9 They generally provide semi-private accommodations with use of a common kitchen, dining
rooms, and bathrooms; and basic services plus necessities such as telephones, storage lockers, and
mailing address.

In general, Safe Havens deliberately wrap their resources around the needs of the individual, rather than
demanding that the individual comply with the requirements of the program. Those served by this
program are typically considered too unstable to be served by traditional shelters, or they have been
banned from them. As one provider described the approach, "This is a program where you can fall back
without falling out of the program" (Fosburg, Locke, Peck, & Finkel, 1997).

Providers of Shelter and Services

Emergency shelter and services for homeless people are provided by a variety of types of organizations,
including government agencies and private groups with or without religious affiliation. Providers of all
kinds may receive ESG funding to support delivery of these services. 10 However, results from the ESG
evaluation indicated that private nonprofit organizations predominated among the agencies actually
funded in 1992. Three-quarters of both shelters and non-shelter providers were private nonprofit
organizations with no religious affiliation, and an additional 19.8 percent indicated they were nonprofits
with a religious affiliation. The remaining 5.4 percent were local government agencies.

8 The differences between the data collected for HUD's 1998 survey and those collected for this evaluation of the ESG program
are attributable to sampling. HUD's study was designed to assess the characteristics of all shelters nationwide, rather than the
subset funded by the ESG program (which does not fund boarding houses, welfare hotels, or SROs).

9 However, if a person's only impairment is substance abuse, he/she may not be considered eligible to stay in a Safe Haven.

10 In fact, almost a fifth of the providers receiving ESG funds in FY91 did not operate emergency shelters. The non-shelter
providers using ESG funds included health care facilities, counseling agencies, residential treatment facilities, local governments,
and a variety of other entities.

National Symposium on Homelessness Research 9-7

Emergency Shelter Services: Opening a Front Door to Continuum of Care

Of the small number of local government shelters, 78.0 percent were 24-hour shelters with day programs,
15.5 percent were day-only shelters, and 6.5 percent were night-only facilities. Among the private,
nonprofit shelters, 69.4 percent of those with religious affiliations and 89.6 percent of those without
religious affiliations were 24-hour facilities.

Most ESG-funded providers were well-established agencies. Just under half of the providers had been
operating for eleven years or more (and a few, such as the American Red Cross, the Salvation Army, and
the St. Vincent DePaul Society, have over a century of experience). About a third had begun operations
between five and ten years before the study was conducted.

The distribution of ESG-funded providers by census region of the country is shown in Exhibit 5. Some
22.4 percent of the providers were located in the Northeast, 33.2 percent were in the South, 24.7 percent
in the Midwest and 19.7 percent in the West. The proportion of shelters in each region was roughly the
same. Over 60 percent of the local government shelters were located in the East or South regions of the
country.

Joint Provision of Shelter and Services

Emergency shelters are not just temporary stopgaps; instead, they are sources of a much wider range of
services for homeless persons. Once in a shelter, what specific essential services are clients offered?
The ESG program evaluation gathered data on the range of activities of ESG-funded service providers
and found that they offered and/or coordinated a considerable variety of services to the homeless. Few, if
any, of the shelters fit the conventional image of a bare-bones, dormitory-style, night-only shelter. They
were not "three hots and a cot." Instead, they were delivering a surprisingly wide range of services on-
site.

9-8 National Symposium on Homelessness Research

•I

c
2>

en
CV

<M £

Iters
Percent

1
1

1— 1

d
o

1-H

w h

t-»

^t-

NO
CM

CM
CM

our
Percent

i
i

1— 1

d
en

1-H

OO
CM

*— 1

d i

ffl

_L **

CM ,fi

r->

^t"

in
CM

i-H

helters
Percent

i— 1

00
CM

l— 1

O !

d
o

■**

-Sv u

.Sf s

z a

00
CM

elters
Percent

c£

o
d

O I

^* fc

C8 *>

a 1

o
d

l-H

C«3

•Q

CO
Ul

-a

-o

T3
,0

Cfl

o
&

3
1

O
CM

T3
CD

-a
to

o
in

O
O

•2

O
H

Emergency Shelter Services: Opening a Front Door to Continuum of Care

Exhibit 3

Shelters, Shelter Bed Capacity, and Average Daily Occupancy:

HUD's National Estimates compared to 1992 ESG-funded Shelters

1992

1992 ESG-Funded Shelters

ESG-Funded

as a percent of 1988

Shelters

HUD 1998

Shelters

HUD National Estimates

Number of Shelters

5,400

2,477

45.9%

Total Bed Capacity

275,000

108,735

39.5%

Average Occupancy

Per Night

180,000

88,276

49.0%

Sources: 1988 data from HUD's 1988 National Survey of Shelters for the Homeless; 1992 data from Provider Phone Survey of
65 1 ESG-funded providers.

Exhibit 4
Average Bed Capacity by Size of Shelter

Percent of

Average

Shelters

Bed Capacity

HUD's 1988 1992 ESG-

National Funded

Survey Shelters

Small (25 or less)

44% 49%

15 15

Medium (26 to 50)

32% 29%

36 37

Large (Over 50)

24% 24%

133 137

100% 100%

Average: Average:
50 50

Sources: 1988 data from HUD'

s 1988 National Survey of Shelters for the Home

'ess; 1992 data from Provider Phone Survey of

651 ESG-funded providers.

9-10

National Symposium on Homelessness Research

• mm

fa
# g

!/>

Ih
4)

"O
IT) O

• mm CL

-2 £

fa e

fa
i

CT>

CJ
CO

CO
Q)

DC
co

CO
CD

CO
CO
_CD
CD

E
o

I
c
o

E
>.

CXI

c
o

8
o

c
o
o

o
o

<u
o

c
H>

u
a
>>

H
u
a>

.o
en

In
<U

V© 2S

" no

a
5

elters
Percen

•o

r-'

-C

<*> h

— a*

l-H

T-H

ON 1

-M

S3
cy

l-H

*r>

« h

24-
umbe

l-H

ON
00

l-H

• fe

-C

M u

Night
umbe

l-H

•*->

helters
Percen

CO
CN

1/3

>» h

« 2

a l

-5:

»H

t_l

■4— »

o
on,

• ?H

• H

Cfl

<*>

l-H

o
ex
g

H
•

--H

€

45
oo

o
Z

Emergency Shelter Services: Opening a Front Door to Continuum of Care

Exhibit 7 summarizes the services coordinated by all providers and indicates whether the services were
funded by ESG, whether the service was provided on-site (rather than at another facility), and whether
the service or activity was required for all clients. 11 A factor analysis of the list of services revealed that
they were offered and/or coordinated by the providers in four clusters:

• core services (sometimes called "concrete services"); 12

• assistance services (including clothing);

• skills development services; and

• intervention/treatment services.

In the category of core services, almost 90 percent of all providers offered bed space, 13 while nearly 80
percent offered breakfast and dinner, and just under 70 percent offered lunch. But a full 93.1 percent of
the providers indicated that they also directly offered other services to their homeless or near-homeless
clients. These essential services fell into the three groups: assistance services; skills development
services; and intervention/treatment services.

The most common assistance services (offered by 90 percent or more of the providers) were help in
obtaining benefits and finding permanent housing. Also quite common were assistance in daily living
skills, transportation, support groups, and job referrals. Nutritional counseling, childcare and clothing
were other forms of assistance offered by a substantial proportion of the providers.

Shown on the second page of Exhibit 7 are five skills-development services that were commonly offered,
including assistance in GED preparation, vocational counseling, and job training. The fourth cluster,
intervention and treatment services, included substance abuse counseling, psychological counseling, and
medical care. Detoxification and other forms of drug treatment were the least frequently offered services
in the entire list of essential services, but they were still offered by nearly a quarter of the providers.

The list of services in the survey did not include "case management."

12 Core services are typically considered operating costs and are allowable operating costs under the ESG program regulations.

13 Recall that some providers are not shelters, and that some shelters are day-only operations that may not offer bed space.

National Symposium on Homelessness Research 9-13

3
3
.C

•C

c
o
O

v.
o
o
Q

c
c

«)

Q)
O

jo*

"55

^,
o

ON
><

(«*

-d
•> c

A fa

" 6

fa
>>>

-Q

TJ
<u
u

.4»

C/3

■*-*

cJ5

5-
PLh

c
O

<£

T-H

i— 1

I-H

# o

'►>

*£

i—i

i-H

•*-*

C/3

xl 1

i-H

^1"

^i-

5
s

-i— >

<D
C
0)
X)
OX)
fi

• i-H

•r-t

c/a

-C

-t— »

a
<u
c
03

• ^H

C/3

on
OX)

• i-H

• i— 1

• 7—1

fi
• i— i

c
o

•H
•4— >

S-H

Oh
Q

• -H

-4->

•-H

e
©

■4-J

-fi

j-h
fi

■i
s

• i-H

(L)

■i— i

•i-H

• i-H

-4— >

«D
O
C
03
■*— <

172

■4— '

a)
o

-4— >

• ^H

c
o

• i-H
■4->

t:
o

!-H

fi
fi
O

1—1
C3
fi
O

•T-H

■4—1
"C

!-H

I-H

OX)

• 1-H

4fi

-i — i

CZJ

'c»

-4—1

t— »

•i-H

• i-H

!/)

-fi

{=s5

tCI

< <

OS
>H
fa

2 ^>

* ^

1/3

.s &

53 o
O £

s *

o
In

o
a

I
I

O) OC C<\ O) \D \D<T) CAO\

cNOooocnio^tcNas

too

on
<U
on
on

too

toO

toi)

-d

too

• H

OX)

OX)
S3

on
S3

•i-H

on
S3

O
O

on
3

toO

• ^H

S-H

• i-H

on
o3

S-H

• 1— 1

■4— >

03
O
O

•i-H

• I-H

$-H

on
03

43
on

• l-H

S3
03

■4— >

too

"03
o

■4— >

■4—>
43

Engl
Subs

O
>>

S-H
■4—>

toO

i-H

-a

S-H

■4—4

-4—1

•i-H

■4—1

•I-H

_—

■4— >

toil

<i)

H-l

Emergency Shelter Services: Opening a Front Door to Continuum of Care

Recent interviews conducted by Abt Associates with a range of emergency shelter organizations reveal
that homeless shelters continue to respond to the needs of the homeless by expanding their programs to
include a wider spectrum of services. Shelter providers now see their mission as opening a front door to
the Continuum of Care, so that their clients are started on a path toward stable independent living.
Consequently, their emphasis is increasingly in the following directions:

Transitional housing services are a component of all the recently interviewed shelter organizations.
Transitional housing offers a supported, temporary place of residence before the client finds a more
permanent housing situation. This topic is covered in the paper that follows.

Another service many emergency shelters are providing to their clients is skills development programs,
which have increased in number and scope since the McKinney Act. Several place an emphasis on
domestic preparedness (housekeeping and budgeting) and issues around adulthood and parenting.

Education and employment training are at the forefront of services for the International Union of Gospel
Missions (IUGM). Fifty of their shelters have computerized education programs, some of which include
an "employment readiness" component. This component is implemented by Worknet, a nonprofit
organization working with missions on employment education programs and helping them to establish
job training. Due to the lack of affordable housing, the Union Missions find it difficult to find permanent
housing situations for clients; as a result, they have placed a greater emphasis on success in job training
and placement as well as follow-up after the client has left the emergency shelter. More than 300
employers are connected to this training and job placement program and provide both temporary and
permanent employment opportunities. Other shelter organizations, such as the Salvation Army, provide
job training in conjunction with local community or county needs. Some of the Salvation Army
missions also provide transportation to jobs and to GED classes.

Many emergency shelters have expanded their child care or child services, to assist families — especially
single mothers — in maintaining or seeking employment. These programs range from offering daycare
services at shelters to helping keep homeless children in their original schools by providing
transportation from shelters to school and back. Other shelter providers, such as Catholic Charities of
America, have had to decrease childcare services due to a decrease in funding.

Shelters are also doing follow-up work with clients. For example, approximately four years ago, Union
Missions began a performance measurement program used by case managers, in which they set goals for
clients and themselves. By setting target numbers for achievement in such areas as education,
employment and housing, case managers are better able to assist the clients with progressing toward
more independent living and track them. In addition, it gives Union Missions a record of work with each
client and a way to measure the overall rate of success.

Other programs offered by emergency shelters that are the result of expanded services in the last decade
include rehabilitation, conflict resolution, violence prevention, GED courses, youth programs, and
assistance for women and children with HIV/ AIDS.

The Role of Case Management

The term "case management" refers to the functions required to pull together and provide linkage to the
network of supportive services providers who can meet the various needs of homeless persons. The
importance of a case manager derives from the understanding that it is extremely difficult for anyone, let

9-16 National Symposium on Homelessness Research

Emergency Shelter Services: Opening a Front Door to Continuum of Care

alone a homeless person, to negotiate the complex and diffuse supportive services systems that have
grown up due to multiple funding sources and different organization objectives. The most frequently
identified functions of a case manager are assessment of services needs, development of a services plan,
linkage to services, monitoring of services provision, maximizing compliance, and client advocacy.

Over eighty percent of the shelters surveyed in the ESG evaluation offered and even required case
management of their clients as a condition of remaining in the shelter or program. Another indication of
the trend toward requiring homeless clients to cooperate with the case management process is the fact
that case worker assessment was a method used by 82.4 percent of all ESG-funded providers to identify
service needs. The role of case managers can vary from place to place. In some instances, they serve as
the primary provider of all services for the homeless client. In other instances, their role is confined to
coordinating the delivery of needed services.

Who Is Served?
Range of Populations

Nationwide, over half the homeless population is made up of single men. Families make up the next
largest segment (about a third of the total). The evaluation of the Emergency Shelter Grants program
indicates that service providers vary considerably in the populations they serve. Shelter providers serve
different clients from non-shelter providers, and different types of shelters (day-only, night-only, or 24-
hour) served different homeless populations, as summarized in Exhibit 8.

The proportion of non-shelter providers indicating that they worked with a particular population was
generally higher than the proportion of shelters reporting working with the same population. This
implies that the populations served by non-shelter service providers are more diverse, while shelters may
have facilities and programs designed for more narrowly targeted groups. The two exceptions to this
observation were that the night-only shelters were slightly more likely to serve single men, and that the
day-only shelters were significantly more likely to serve single youth.

National Symposium on Homelessness Research 9-17

c
o
o
o

o
o
Q

c
o

CO
CO

C/3

qo Z

.13 T3

4© S

-S3
CO

4©

-d

>■
u
<u

c
_©

p— 1 ^

5 -A

r— 1

< C/J

S3 -*^

r*;

C/3

^i-

Ui CO

5-<

o <w

1-H

<N V)

73 co

!>;

t>;

-H

CX)

-H

rs c/3

^» CO

5 o>

o +->

^ "5

T— 1

03 pS

Q <»

• .

• i-H

too

CO
CO

8
*

43
O

T3
C
cd

•!-H

r^H

• ^H

• i— I

• I— 1

'Ho

• i—i

LTD

'Ho
c

• i-H

Emergency Shelter Services: Opening a Front Door to Continuum of Care

These exceptions are consistent with the remarks of providers during site visits to the State and local
agencies that administer federal emergency shelter funding (the ESG grantees) and to the providers they
fund in fifteen locations around the country. 14

Families, which make up approximately one-third of the homeless population nationally, were the most
frequently cited population served by the ESG-funded providers. Eighty-five percent of all providers
indicated that they served families, including 82.7 percent of shelters and 95.4 percent of non-shelter
providers. Among the shelters, almost all of the day-only and 24-hour shelters served families, while
only 57.7 percent of the night-only facilities reported that they could accommodate families.

While single men account for more than half the homeless population nationally, they were only served
by about half the ESG-funded shelters. However, about three-quarters of the non-shelter service
providers reported offering services to single men. Two-thirds of day-only shelters and 83 percent of
night-only shelters worked with single men, while only 38.4 percent of 24-hour shelters provided services
to this population. In one place, a shelter ran 24-hours for families, but single men could only be there at
night.

Single youth (approximately 4 percent of the homeless population nationally) were the least frequently
served population across all types of ESG providers when the research was conducted. Only about one-
third of both shelter and non-shelter providers offered services to homeless single youth, and a similar
proportion of shelters worked with young people.

Providers also reported whether they work with particular subgroups of the homeless, or with families or
individuals with particular characteristics or problems. About half of all providers indicated they offered
services to battered women and drug-dependent or alcohol-dependent clients. Between 42 and 45 percent
reported working with the elderly, veterans, and the physically disabled, while 37 percent offered
services to the chronically mentally ill. HIV- positive clients were served by 39 percent of the providers,
and mentally retarded individuals received services from 30 percent of ESG-funded agencies. Children
and youth were served by only 23 percent of the providers. Recent interviews indicate a growth in the
number of families (especially women with children) served over the past decade. In response, the
Salvation Army increased access for women and children to its shelter facilities from 70 to 90 percent.

Prior Residences

If emergency shelters are meant to function as a front door to the Continuum of Care, how do homeless
people find their way there? The ESG evaluation is a good source for the population as a whole,
although there have also been studies that asked this question about special populations. 15 Some
combination of four circumstances (living on the street, living with friends/relatives, private rental
housing, and emergency shelters) accounted for a substantial proportion of most providers' clients. 16

14 It is noteworthy that single youth, especially teenage males, are frequently not allowed in night-only or 24-hour shelters. The
day shelters are their only alternative. Having to return to the streets at night, they are a very vulnerable special needs group.

15 See Fosburg, et al. (1997) for a discussion of the Shelter Plus Care program administered by HUD. Eligible program
participants targeted by this program are disabled homeless persons (and their families) who have serious mental illness, chronic
alcohol or other drug problems, acquired immunodeficiency syndrome (AIDS), or some combination of these disabilities.

Among homelessness prevention providers, a substantial proportion of the client population came from a housing rather than
shelter situation; a total of about 40 percent of these clients came from private rental housing, public housing, or an owner-
occupied home. An additional 16 percent were living with friends or relatives. This latter group was at the greatest risk of
homelessness. Other prevention efforts were directed toward placing shelter residents in permanent housing.

National Symposium on Homelessness Research 9-19

Emergency Shelter Services: Opening a Front Door to Continuum of Care

The prior residency of the clients of each type of shelter varied widely, as shown in Exhibit 9. Night-
only and day-only shelters tended to draw clients from the streets. The 24-hour shelters drew most of the
their clients from a combination of the streets, living with friends and relatives, and private rental
housing. Non-shelter service providers tended to draw the highest percentage of their clients (21.7
percent) from private rental housing, suggesting that people at risk of homelessness sought help from the
non-shelter service providers first. However, the non-shelter providers were also drawing from the
streets (16.5 percent), from people living with friends and relatives (16.6 percent), and from emergency
shelters (13.9 percent).

Referral Sources

According to the providers, clients learned about the services they offered from numerous referral
sources, as shown in Exhibit 10. The top four sources of referrals — social service agencies, clergy,
friends, and other shelters — were a source of clients for virtually all shelters, regardless of type. Other
very common sources included citizens, doctors, police and the courts, public housing agencies, parents,
and hot-lines. Detoxification and substance abuse treatment facilities, as well as psychiatric programs
and treatment centers, were also important referral sources, suggesting ways that some special
populations were linked into the shelter system. The numbers of different referral agents reported by the
providers and the substantial percentages reported for many of them underscore the strength of the
providers' networks and their reputations in the community.

By and large, the sources of client referrals were similar for all types of shelters, with one exception: the
day-only shelters were much more likely to have clients referred to the program by their own outreach
workers. Only 22. 1 percent of all ESG-funded providers reported that they employed outreach workers
to help identify people who might benefit from services. Of those who did, 81.5 percent had their
outreach staff contact social service providers, and 66.5 percent contacted local police to identify
potential clients. Roughly half contacted public housing agencies, detox or substance abuse treatment
facilities, and psychiatric facilities.

9-20 National Symposium on Homelessness Research

5
o

.2 <v

o
©

T-H

o
o

T-H

C«

— , Sh

■-J fl cu

* s

T-H

9 1

L- ^ fe

T-H

I '—

ij S

T-H

•

T-H

T-H
T-H

a «

•
•

CL,

.©

«\
CM

■a
c

•i-H

T§

^J-H

• i-H
CO

CD
*h

•i— 1

Sh
<D

H->

O
CD

•iH
CO

O
45

8
<*>

■4— >

• tH

•i-H

h-l

*h
Cm

S
w

■ H

•i-H

3
.C

c
o
o

o
o

O)
C

5
&

Q)
t O

»~

Q>
CO

a
>->

In
*=<

izi

e
u

* to

a
u

M
&
c

a>
U

CD
CJ

<£

*<t

d
o

"*■"

Tt-'

d
o

.2f

, — i

*-*
S3

d
o

\6
oo

vd
oo

r-l

On'
00

>►>

42
&

^t-

ti-

^1-

Tl-

• 9

4->

>.
•<•*

4->

•4— •

ft*

4->

• i— (

t/j

• i— i

5-H

5-h

4->
C/3

4— >

C3
5-i

5-i
Oh

•l»*

■t-j

C/3

<*>

5-1

• i— i
5-i

4->

o
a

1— H

• 1— 1

'__,

-o

a)
o

• H

• i— i
43

C/3

O
CO

5-H

• i-H

"<3
3

•■e
&

-O

i— I
OS

fa
a

• pa

</"

L.
0>

■d

o
u
fa

-a
-a

2 §

*S L

3 O
•- c«

■**
s

-+-»

a
v

*— i

S-I

S-I
cy

©'

"aS

Cfi

»n

'nT

^j-

»n

^J-

T-H

"a>

T— 1

T-H

d
o

■^

^f"

T-H

"tf

i-H

^1-

• •

S-H

00
5-1

C
CD
Q

5-i

-t— »

+— *

<^>

•>—>

S-H

T3
53
c^3

•rH

• I— 1

C/3

CD
43
O
S-i
3

S-i

l-H

-4— >
• i— 1

<D
O

■4— >

S-i
OD

5-1

C#5

•»-»

+-»

Or
Cfl

c
o
a

• f-H

43
U

bJO

5_i

00
CD

43
on

5-i

_CJ

• 1— 1

• i-H
S-H

•4-^

• i-H

o
co

• i— i

S-i

Oth
Citi

o
o

OO
C-H

Emergency Shelter Services: Opening a Front Door to Continuum of Care

Estimates of Population Served

In 1992, the ESG program supported organizations that served nearly 4 million individuals and families
in a variety of ways, as well as helping prevent loss of housing for some 35,000 households. Almost 28
million days/nights of shelter were provided. 17 Although duplication (multiple counting of an individual
or family) is a chronic problem with counting the homeless, the data gathered for the ESG study were
closely scrutinized and (based on their consistency with other measures and data sources) appear to have
substantial credibility. Overall, the shelters in the ESG study reported an average nightly census of 40
persons over the previous 12 months, or an average of 12,644 shelter days/nights for the year. In the
absence of recent systematic data, it is difficult to determine how the number of emergency beds has
changed over the past six years. 18 However, one indication of the growth in the number of homeless over
the last several years is that the Salvation Army alone provided 6 million emergency bed nights in 1997.

In HUD's 1988 survey of shelters, it appeared there were sometimes mismatches between the type of
shelter space available and the type of client needing shelter. HUD's survey findings suggested that
spaces were generally available in a jurisdiction's larger homeless shelters, but these facilities generally
offered only the "concrete services" of beds and meals. Spaces at smaller facilities that offered more
services seemed always to be at a premium.

Shelters in the ESG study reported that, on average, they operated at 78 percent of capacity. 19 Small
shelters (those with fewer than 25 beds) reported an average occupancy rate of 72 percent, and medium
(25 to 50 beds) and large (more than 50 beds) shelters indicated they operated at 82 percent of capacity,
on average. About 5 percent of the shelters reported that their average nightly census exceeded their
number of beds: they regularly served more homeless families and individuals than the number for which
they had appropriate space.

All the providers interviewed in 1998 indicated their facilities were full to capacity each night. In fact
one of them, Catholic Charities of America, reported that emergency services are in such great demand
that funding for other programs within the organization has been reduced to accommodate emergency
shelter needs. In the ESG study, some 80 percent of providers nationwide indicated that they had turned
eligible clients away. The average number of eligible clients turned away in the past 30 days was
reported to be 43, with shelter operators reporting an average of 48 turnaways.

What are the reasons clients have been turned away? The ESG evaluation reported the primary reason
was that the shelter or program was at capacity. The next three most frequently cited reasons for these
providers were security problems (especially in shelters undergoing renovation), an inebriated client, or
the wrong type of client.

The shelter providers in these figures were estimated to cover about 40 percent of the shelter bed capacity nationwide and
about 50 percent of average nightly occupancy.

1 8 Again, once they are analyzed, data from the 1996 National Survey of Homeless Assistance Providers and Clients will
provide updated figures on shelter capacity.

19 For purposes of analysis, occupancy rate was calculated by dividing the provider's reported bed capacity by the reported
average nightly census. Computed occupancy rates that exceeded 150 percent of total bed capacity were excluded from the
average figure.

9-24 National Symposium on Homelessness Research

Emergency Shelter Services: Opening a Front Door to Continuum of Care

Factors Related to Length of Stay

How long do clients remain in emergency shelters? What factors influence their length of residency?
Exhibit 1 1 presents data from the ESG study on these subjects. Across all the shelters, the mean length
of stay was 71 days and the median was 30 days. However, this varied greatly, from a few shelters with
mean stays of less than 5 days to a handful reporting average stays over a year. The 24-hour shelters had
the longest median stays, at 30 days; the small number of day-only shelters showed great variability in
length of stay. 20 But for 95 percent of these agencies, the average duration of residence per client was 9
months or less.

Among the emergency shelters interviewed in 1998, the average length of stay ranged from 10 nights to 9
months. This variation resulted from the different kinds of programs the shelters offered ranging from
limited-stay bed use to housing units that could be considered transitional.

In the 1992 survey, shelters reported varying standards on the maximum allowable length of stay
(possibly depending on the type of client). About three-quarters of the shelters characterized themselves
as short-term shelters, with maximum allowable stays of 90 days or less. Half of the shelters indicated
they served as temporary, overnight facilities, while the other half reported they provided long-term,
transitional shelter (over 90 days, but with some prescribed limit). Just under 30 percent of the shelters
said they served clients with special needs (such as substance abusers) and imposed no limits on length of
stay.

A range of factors was identified by shelter providers in the ESG study as influences on length of stay.
The three factors most frequently cited by the agencies were:

• the extent of the client's problems;

• the degree of client cooperation; and

• the availability of permanent housing.

20 No direct data on shelter time limits are available from this study.

National Symposium on Homelessness Research 9-25

a
5

3
3
,C
■C

c
o
o

o
o
Q

c
c

c
2>

ft,
>>

u
a>

■*■*

"33
co

C
C

-*^

^ ^

1/3

vq ^q

r— 1

r-H t-H

•4-*

^1"

CO <N

c/3

<*■»

pfl

^sO

^o m

r^*

VO Tt

i— i

-*-*

^ c#

i
i

<N od

^f-

^h cN

C/5

m in

T-H

^1-

^H CO

T-H

• •

toJQ

2 s

•5
•9P

• l-H
CO

•5!

-C

«0

■4— »

6»5

5-4

-t— >

•»>*

S-H

a,
•*— >

•T— 1

-♦-J K*^

73
o

helter time limi
inancial stabilit

C
O

1**

too
S

Mean
Median

•»»*

5
o
e

4- >

•*— >

• H

• i— (

i— i

• i-H

+->

CO Ph

&
"35
.a

s*
^ oc

^ 2

a ft
•S "O

-C <U
8 IS

_r ft
2 °?

■9 w

W fi

>>
OS

B
a>

*j
B

.Si

-*->

5fi

^st-

«fr

S-

T-H

T— H

T-H

O
^0

T-H

i
i

p
in

p
00

i-H

Xfl

-Q

T—H

T-H

^1-

«n

• •

bfl

•5

• 1— 1
O

»S»

•-

tzi

-t— 1

t/3

«>a

•*— >

•i-H

•»»i

S-h

5-H

■H

-(->

>»

Oh
<H-I

<H-H
O

• 1—1

• i-H

• ^H

-4-J

• »— (

o
a

too

s»

Mean
Median

■ H
O

-t— >

• ■—I

.1— (

• i-H

• 1— 1
-4— >

J-H

•1— i

■4->

Vh
(D

-*— 1

Emergency Shelter Services: Opening a Front Door to Continuum of Care

While the first two factors would affect how soon a client could be ready for transition from the shelter,
the third could limit the departure of even the most ready clients. Client financial stability was among
the other factors prominently mentioned, as was expiration of the shelter time limit. Although nearly 80
percent of the providers in the study reported turning away eligible clients, availability of services or
staffing or funding was not often given as a limiting factor once a homeless person or family was in a
shelter.

Effective Practices in Emergency Shelter and Services

In the decade's experience with sheltering homeless individuals and families, a number of practices have
proven useful in assisting clients and have been very widely adopted. One of these — the joint provision
of shelter and services — is in fact the basis for a number of other practices.

The combining of core services and essential services, described earlier in this paper, occurs in two
different ways. One is the on-site provision of services to residents of a shelter by an outside service
provider (e.g., a hospital with a clinic on the premises). The other is the offering of services by the same
provider that operates the shelter. In either case, many shelter providers have gradually added services,
typically on site or nearby, to meet the needs of their clients. Many of the providers surveyed used ESG
support to expand existing services and/or to start up new services.

Client Needs Assessment

Client needs assessment is widely considered a critical factor in effective service delivery to homeless
people. The assessment process serves a number of purposes, including developing a relationship
between the staff member and guest and beginning to establish trust, as well as determining the services
(and possible outside referrals) that the individual or family needs in order to regain its independence and
residential stability.

Providers used a variety of methods to assess the service needs of their clients, as shown in Exhibit 12.
Essentially all providers reported using intake interviews, assessments provided by referral agencies, and
clients' own evaluation of their needs as ways of assessing clients' needs. There were practically no
differences among the various shelter types, except that the day shelters were significantly more likely to
offer/use medical examinations and diagnosis to assess the needs of the clients. Another indication of the
trend toward requiring homeless clients to cooperate with the case management process is the fact that
case worker assessment was used by 82.4 percent of all ESG-funded providers to identify service needs.

9-28 National Symposium on Homelessness Research

u
<y

"33

c* ■£

1-1 c

*- .a
is

C
Cm

"■3

4>
T3

1/3

T— 1

Iters
Perc<

On
in

l— 1

OO
CN

pfl

C/3

— u

w-m 1 Cl)

< f

00
00

o
en

<r-4

*sO

«t

l - H

Shelter
Percent

d
o

i— 1

3 n

.2 S

CT\

en
in

r-H

1— 1

T-H

i-H

5h
CD

-4— »

•i-H
CO

O
C
W)

•l-H

d
CD

•l-H
4->

4— >

CO
CO

co
CD

■4— »

(

4->

• i— i

^— >

cd
CD

i— i

C/3

-a

cd
CO

5-(

4— >

O i

CO
CD
CO
CD
CC

CO
CD

c
w

CO
CD

E
o

X
c
o

3
CO

E
>.
(T>

"co

c
o

Emergency Shelter Services: Opening a Front Door to Continuum of Care

Shelter Rules and Requirements

Another widespread practice of emergency shelters is the use of rules and requirements to guide and limit
clients' behavior while in residence. In the ESG evaluation, querying providers on this topic produced a
lengthy list of rules. As shown in Exhibit 13 the most common rules prohibited drinking or drug use
(found in 98 percent of the shelter facilities) and forbade weapons possession, stealing, and assault
(found in 97 to 98 percent). Ninety-four percent of shelters imposed a curfew on the clients. Other
common rules prohibited prostitution and consensual sexual activity. And the rules continue, as shown
in the exhibit.

Requirements of participation in certain activities are another common practice, used by shelters to help
limit client dependence and end the spell of homelessness. A large proportion of the shelters in the ESG
program evaluation had certain requirements that clients had to fulfill, in order to remain in the shelter.
The most common requirement reported by shelters in the ESG evaluation was meeting with the
caseworker. Overall, 83 percent of the shelters made clients do so, but the proportion was substantially
less in day and night-only shelters than in 24-hour ones. Clients also commonly had to actively seek
housing (82 percent), enroll and keep their children in school (77 percent), and adhere to a case
management plan (75 percent).

Most providers reported that participation in the range of essential services was voluntary rather than
required of their clients. However, 30 percent did require clients to take advantage of assistance with
daily living skills, and 32 percent required participation in support groups. Most providers offered these
additional services on-site, rather than referring clients to other agencies.

Indicators of Effective Coverage of the Homeless

Over time, the State and local agencies that administer federal emergency shelter funding (the ESG
grantees) have developed strategies for targeting the unique needs of specific segments of the homeless
population. As shown in Exhibit 14, most grantees cite numerous targets for the ESG funding. Nearly
all grantees (98.6 percent) indicate that they recognized the needs of homeless families. In keeping with
this, most grantees (91.4 percent) have included victims of domestic violence in their strategies. The
needs of the chronically mentally ill have been recognized by 72.2 percent of the grantees. The elderly
and veterans have been recognized by 52.0 to 56.2 percent of the grantees. Others (homeless youth,
migrants, those infected with HIV/AIDS, and substance abusers) have received less recognition in the
deliberate development of strategies for addressing the needs of the homeless.

9-30 National Symposium on Homelessness Research

•4-4

"33

!/)

>>>

-©

OJD
©

a-
c

2 ^

.£ ©
IS o.

* &

■

u
,©

'>
es

j=
<u

ffl

.2
U

I/)

•*•*

i—i

H-4

"a3

-3

C/3

T-H

Tfr

1-H

i-H

-sf

i-H

■*^

i— H

»— 1

»r^

U
4)

l/S

3
O

S-i

ffl

I-H

^t"

>->

3
O

3
<D

• iH

OX)

•i-H

'o
o

■4—1

•H

• 1-H

13
3
O

• i— i

■4-4
•i-H

T3
3

■4—4

-4—4

<+h

4—1

•I-H

OX)

•^H

• iH

on
3
OD

§•

<+H

CO
00

Sh
D

Oh
M-H

■4-J

■4—1
• I-H
■4—1

O
u

O
oo

a
o

D
oo

H-H

•i-H

-4—4

H
3

c3
3

D
oo

•I-H

<+H

3
D

3
03

oo
3

OX)

T3
^O

S-H

-3

• i-H
•4—>

• i-H
>

OX)

1=1

S-i

4>
1/3

3
O

^ob

■c

• i— i

OO
1/3

i— <

00
-4-4
O
3

3
o3

■4—1

oo
3

•!-H

■4-4

• 1-H

OX)

'5b

OX)

• i-H
-4—1

+- >
oo

■4—4

&o
3

■4—4

3
CD

i-H

-a
O

S-H

•i-H

■4—4

r— H

■4—4

3
<D
H

• i— i

■4—4

3
<D

3
OX)

OX)

•c

-3

-4—4

•^H

• 1-H

-3
<D

■>—>

• i-H

■ — H

4-H

8
3

o
Q

Q)
O

CD
CO

i-
CD

1—

"cd

■c
co

VI
V}
9i

■**

WD
C

jO 0)

£3

c
©

c
O

-w

^t-

T-H

S-

•<

^■^

T-H

r— I

t-H

T-H,

•
•

<*>

CO
CD

CD
CJ

• 1— I

• i— i
-<— >
CO

• i— i
"cd

• 1— 1
T— 1

• 1—1

4-»

3
o

^-i

r— H

CM
CO

CO
CO

CD
CD

1— t

•i-H

CD
T3

■4—*

h— 1

CO
CD

•i-H

a— »
CD

•fH

ffi

S
•-B
S

o»
JS

•**

o
£

a
s
©
u

* CO

^ ©

c
©

■*-

•+*

s fi

* 8

i-H

CO*

^■■N

•
•
•

co
to

a
"o

•i-H
>

•1-H

•i-H

•**

O 4

*—>
o

•i-H
■ 1-H

■S

CO
CO

o
a

• i-H

S
o

i-H

+->
>

+-»

■ 1— (

G
O
H

cd
u

•i-H

l-H

<
>

I-H

w
a>
OC
co

w
w

E
o

X
c
o

"(0

c
o

Emergency Shelter Services: Opening a Front Door to Continuum of Care

Despite the grantees' identification of particular groups of the homeless for development of strategies to
meet their needs, their self-rating of effectiveness (on a scale of one to five) in addressing the needs of
the special groups varied. Grantees indicated that their strategies were most effective (mean rating of
4.1) for victims of domestic violence. The next highest rating of the grantees was for their strategies to
meet the needs of homeless youth (3.9). Given the general lack of services to this special group, as
reported by providers, this grantee opinion is viewed as questionable. What is more probable is the
reported effectiveness of the services for homeless families (3.8) and the homeless elderly (3.5).

Future Research Needs for Emergency Shelter and Services

The problem of homelessness — and the challenge of helping homeless people to find stable housing and
achieve independent living — are not likely to disappear soon from the United States. The current healthy
and buoyant economy has not eliminated the need for emergency shelter and services, and some factors
are likely to intensify this need in the short term. Among them are increasing price pressures on
affordable housing as local markets heat up, reductions in the supply of affordable housing due to public
housing demolitions and to prepayments/opt-outs in the private assisted stock, 21 and welfare system
changes that will cut significant numbers of families from the TANF program within the next six months.
Beyond these factors, substance abuse and mental illness will continue to contribute to loss of permanent
housing, as will domestic violence and health emergencies that wipe out people's resources to make rent
or mortgage payments. An economic downturn in the future could lead to loss of jobs and housing for
families and individuals now living at the margin.

If the need for emergency shelter and services will continue to be felt, then there is also substantial need
for related research. One area of need is for an up-to-date picture of the shelter and service agencies and
their clients. The National Survey of Homeless Assistance Providers and Clients, conducted by the
Census Bureau between October 1995 and November 1996, collected information about the providers of
homeless assistance and the characteristics of homeless persons who use their services. Analysis of the
data, currently underway, should produce newer estimates of shelter capacity and utilization, as well as
current information on the kinds of services being provided in these settings.

Nevertheless, many other aspects of this topic are not currently being studied. Research is needed in
these areas:

What are the main strategies being used for homelessness prevention, and what has been the impact of
these interventions? A thorough study of prevention would include careful investigation of the program
types, the criteria for selecting the populations served, and the impacts, to determine the types of
circumstances in which specific prevention methods can be effective.

There are differing needs among different groups in the homeless population. The needs of families with
children — and of unattached youth — are not likely to be the same as those of homeless individuals with
chronic mental illness, substance abuse problems, or HIV. On the other hand, there could be significant
areas of overlap (especially regarding substance abuse). Careful research on the different subpopulations
and their needs, carried out over an extended period, could help improve service targeting and could
reveal whether the causes of homelessness are changing over time.

-' HUD's 1997 Report to Congress on Worst Case Housing Needs finds that the stock of rental housing affordable to the lowest
income families is shrinking, and Congress has eliminated funding for new rental assistance since 1995. Further, worst case
needs are increasing fastest among the working poor. See Rental Housing Assistance-The Crisis Continues (The 1997 Report to
Congress on Worst Case Housing Needs) (Washington, DC: US Department of Housing and Urban Development, April 1998),
Executive Summary.

9-34 National Symposium on Homelessness Research

Emergency Shelter Services: Opening a Front Door to Continuum of Care

As Burt (1998) has noted in her paper for this symposium, with respect to services, we know
considerably less about what works for homeless families than we do about assisting the special-needs
parts of the homeless population. Clearly, affordable housing — or provision of housing subsidy through
public housing or Section 8 — appears to be an important factor in stabilizing formerly homeless
families. 22 But is it sufficient? What about the role of case management and stabilization services, with
or without transitional housing? 23

More generally, we do not have good data or analyses on the effectiveness of services designed to move
poor families toward economic self-sufficiency. Despite the welfare system changes that put such a
premium on entering the world of work, we have little systematic knowledge of what means are effective
in helping single parents make this transition, or of the circumstances in which particular interventions do
help. Thus, research needs to be conducted in a variety of settings, including homeless shelters and
transitional housing (but also including public housing and other places where there are concentrations of
low-income families) to address the challenges these families increasingly face.

The last of these proposed study topics suggests that research on the homeless and research about other
parts of the low-income population should be closely linked. Especially in light of the evidence that
homelessness is episodic, we need to focus more on why — and when — families and individuals lose their
ability to live independently. In the coming winter of welfare cut-offs and continuing shrinkage of the
affordable housing stock, this question could become the most urgent one of all.

22 An analysis challenging the view that expansion of subsidized housing will reduce the number of homeless people can be
found in Dirk W. Early, "The Role of Subsidized Housing in Reducing Homelessness: An Empirical Investigation Using Micro-
Data" Journal of Policy Analysis and Management 17:4 (Fall 1998), pp. 687-696.

In studies of the Homeless Families Program, which combined case management and Section 8 housing (and which was
sponsored by HUD and the Robert Wood Johnson Foundation), researchers reported that there were encouraging gains in
residential stability but that families were still heavily reliant on federal support. The lack of progress in employment suggested
questions about how durable the gains in stability would be. See D. Rog and M. Gutman, "The Homeless Families

National Symposium on Homelessness Research 9-35

Emergency Shelter Services: Opening a Front Door to Continuum of Care

References

Early, Dirk W. (1998). The Role of Subsidized Housing in Reducing Homelessness: An Empirical
Investigation Using Micro-Data. Journal of Policy Analysis and Management 77(4): 687-696, Fall.

Feins, J. D., Fosburg, L. B., & Locke, G. (1994). Evaluation of the Emergency Shelter Grants Program.
Washington, DC: U. S. Department of Housing and Urban Development, September.

Fosburg, L. B., Locke, G. P., Peck, L. & Finkel, M. (1997). National Evaluation of the Shelter Plus
Care Program. Washington, DC: U. S. Department of Housing and Urban Development, October.

Rog, D. J. & Gutman, M. (1997). The Homeless Families Program: A Summary of Key Findings. In S.
L. Isaacs & J. R. Knickman (eds.) To Improve Health and Health Care: The Robert Wood Johnson
Foundation Anthology. San Francisco: Jossey-Bass Publishers, 209-231.

U. S. Department of Housing and Urban Development, Office of Policy Development and Research.
(1989). 1988 National Survey of Shelter for the Homeless. Washington, DC: U. S. Department of
Housing and Urban Development, March.

U. S. Department of Housing and Urban Development, Office of Policy Development and Research. .
(1998). Rental Housing Assistance — The Crisis Continues (The 1991 Report to Congress on Worst Case
Housing Needs). Washington, DC: U. S. Department of Housing and Urban Development, April.

U. S. General Accounting Office. (1987). Homelessness: Implementation of Food and Shelter Programs
under the McKinney Act. Washington, DC: U. S. General Accounting Office, December.

9-36 National Symposium on Homelessness Research

Transitional Housing and Services: A Synthesis

by
Susan Barrow, Ph.D.
Rita Zimmer, M.P.H.

Abstract

Despite HUD's endorsement of transitional housing as an essential part of a comprehensive continuum of
care, consumers, providers, and advocates have frequently disagreed on its value, on the best ways of
linking services to housing, and on appropriate mechanisms and sources for funding transitional housing
programs. Critics have emphasized the stigma associated with transitional programs as well as the
diversion of resources that might otherwise serve to expand the supply of and access to affordable
permanent housing; proponents counter that homeless families and individuals with multiple problems
need help with more than housing alone if they are to achieve residential stability. To sort through the
conflicting claims about transitional housing requires some consideration of the diversity of the programs
thus labeled and what we do and don't know about their impact on homelessness. We begin by clarifying
what the concept encompasses; review the evolution of transitional housing; and describe variations in
the major approaches developed for homeless families and individuals in terms of differences in target
populations, physical structures, service intensity, and other program characteristics that cluster along a
continuum with "high demand" service-intensive facilities at one end and "low demand" programs with
flexible requirements and optional services at the other. Available research assessing the major models
indicates that scattered-site transitional housing programs that convert to permanent housing constitute
one effective (and cost effective) approach to helping families and possibly individuals exist from
homelessness. Future research should not only test the relative effectiveness of different transitional
program models but should compare transitional housing approaches to alternative strategies for ending
homelessness for individuals and families.

Lessons for Practitioners, Policy Makers, and Researchers

• Transitional housing is controversial. Critics view it as stigmatizing, de-stabilizing, and a drain on
resources better used for permanent housing; proponents view is as the best way to ensure homeless
families and individuals get the services that will enable them to attain and sustain self-sufficiency as
well as permanent housing.

• Programs vary in numerous ways — including target populations, physical structure, service intensity,
admission thresholds, and conditions and duration of tenure. Although there are almost limitless
combinations of these dimensions, program characteristics tend to cluster along a continuum, with
"high demand" (e.g., congregate, structured, service intensive) programs at one pole and "low
demand" (e.g., dispersed, flexible criteria, optional services) at the other.

• Research on transitional housing indicates that adding low demand transitional housing to outreach
or drop-in services for homeless individuals improve their likelihood of obtaining permanent
housing.

• Transitional programs at the "high demand" end of the continuum usually serve individuals and
families with multiple problems. Research suggests that highly structured facilities which double as
treatment programs for people with severe mental illness and/or substance abuse problems improve

National Symposium on Homelessness Research 10-1

The contents ot the papers tor the National Symposium on Homelessness Research are the view of the author(s) and do not
necessarily reflect the views of the U.S. Department of Housing and Urban Development, the U.S. Department of Health and
Human Services, or the U.S. Government.

Transitional Housing and Services: A Synthesis

housing and clinical outcomes for those who remain until they graduate, but they also have extremely
high attrition rates. For most who enter them, they are not a route out of homelessness. Providers
are encouraged to experiment with alternative approaches for those with multiple problems.
Research findings show that scattered-site models of transitional housing that "convert" to
subsidized permanent housing are a cost effective approach to helping families transition out of
homelessness without the stigma and disruption of support networks that facility-based approaches
may entail. Some variants of this model also add to the permanent housing stock by restoring
deteriorated units. Convertible models have been developed for individuals as well, and providers
are encouraged to continue to develop this approach.

Provider experience underscores the importance of issues of scale, community networks, and "fit"
with the fabric of the community — not only to foster community acceptance of transitional housing
programs but to enhance safety and stability for residents and neighbors alike.

Transitional housing can only be effectively implemented in the context of a continuum of resources
that includes adequate permanent housing and the supportive community-based services that can
prevent returns to homelessness.

10-2 National Symposium on Homelessness Research

Transitional Housing and Services: A Synthesis

Introduction

Rapidly rising homelessness in the late 1970s and early 1980s initially evoked crisis responses from
federal and local agencies — responses focused on expanding the capacity for emergency shelter. Only
later in the 1980s did the emphasis shift to developing housing and service combinations that would
address longer-term needs of the homeless population. Federal support for both transitional and
permanent housing has been provided since 1987 with McKinney Act funds; and since 1994, when the
U.S. Department of Housing and Urban Development (HUD) began to require that applicants for federal
funds create an integrated "continuum of care," transitional housing has been deemed one of the
necessary components of a comprehensive response to homelessness (HUD Report to Congress, 1995;
Barnard-Columbia Center for Urban Policy, 1996).

Despite HUD's endorsement of transitional housing as an essential part of the continuum of care,
consumers, providers, and advocates have frequently disagreed on its value, on the best ways of linking
services to housing, and on appropriate mechanisms and sources for funding transitional housing
programs. Critics have emphasized the stigma associated with transitional programs as well as the
diversion of resources that might otherwise serve to expand the supply of and access to affordable
permanent housing; proponents of transitional housing counter that homeless families and individuals
with multiple problems need help with more than housing alone if they are to achieve residential stability
(HomeBase, 1998).

To sort through the conflicting claims about transitional housing requires some consideration of the
diversity of the programs thus labeled and what we do and do not know about their impact on
homelessness. We begin by clarifying what the concept encompasses and where the boundaries between
transitional housing and related concepts — emergency shelter, residential treatment programs, permanent
supportive housing — can most usefully be drawn. We then review the evolution of transitional housing
for homeless families and individuals and the major approaches that have been developed for each of
these groups. Finally, we examine the relatively limited research literature on the effectiveness of the
major models, and conclude with a discussion of unresolved issues requiring further study.

Concepts and Definitions

In the content of a continuum of responses to homelessness, transitional housing occupies an
intermediate position. It consists of relatively private accommodations provided on a temporary basis
along with intensive services intended to facilitate the transition to permanent housing. The distinctions
between transitional housing and other types of temporary and/or service-enriched accommodations for
homeless people are not hard and fast: what one locality labels as "transitional" may look a lot like the
"shelters" in another setting. Despite this overlap, however, we can clarify core features by examining
how transitional housing contrasts with emergency shelter, residential treatment programs, and
permanent supportive housing.

Transitional Housing vs. Emergency Shelter

Transitional housing usually differs from emergency shelter in offering smaller facilities, more privacy,
and more intensive services with greater expectations for participation. While shelter services address
basic needs (food, clothing, a place to sleep), the services in transitional programs almost invariably
extend beyond meeting survival needs. They tend to be coordinated by case managers and are geared
toward helping residents define goals and achieve greater independence. Finally, transitional housing is
almost always time limited, with lengths of stay usually capped somewhere between three months and

National Symposium on Homelessness Research 10-3

Transitional Housing and Services: A Synthesis

two years. Emergency shelter stays, in contrast, tend to be either more limited (e.g., less than thirty days)
or, in places where the courts have mandated the provision of shelter, unlimited 1 .

Transitional Housing vs. Residential Treatment Programs

While it is in the context of widespread homelessness that transitional housing programs have
proliferated, transitional accommodations play a role in other types of continua as well. As the locus of
mental health care shifted from institutions to community settings, a graduated series of transitional
residence programs emerged (Arce et al., 1982) to facilitate ex-patients' adaptation to community living.
The substance abuse treatment system, likewise, has produced a continuum that usually begins with
detoxification, followed by short-term rehabilitation and long-term residential treatment — all conceived
of as transitional steps en route to recovery. As homelessness has increased in the mentally ill and
substance abusing populations served by residential treatment programs, they increasingly double as a
transitional stage in both rehabilitation or recovery and in the process of exiting from homelessness.
There has in fact been little consideration of how these two processes are related, whether the transition
out of homelessness entails distinctive service and housing issues, and how these are related to those of
recovery and rehabilitation.

Transitional Housing vs. Permanent Supportive Housing

The boundaries between transitional and permanent housing are clearer, although here, too, there are
ambiguities. In general, transitional housing is time-limited; permanent housing is not. And, when
residents reach the time limits built into transitional housing, they are expected to "graduate" to more
independent, "normal" housing settings. Thus transitional housing is a stage in a progression, while
permanent housing entails no assumptions about personal growth and development. An additional factor
that sometimes distinguishes transitional from permanent housing is tenancy rights. For transitional
residents, tenure is usually contingent on participation in services and compliance with program rules,
whereas permanent tenants usually hold leases and have full tenancy rights. 2

Why Transitional Housing? Evolution of Concepts and Practice

During the 1980s, there were major changes in both the population affected by homelessness and in
government and community responses. These shifts were reflected in the 1987 Stewart B. McKinney
Act, which supported a varied set of housing and service programs to assist an increasingly diverse

Local variations in the availability of both shelter resources and affordable permanent housing influence lengths of stay, as do
political and legal factors. In New York City, for example, several court decisions have bearing on how transitional housing has
developed. An early law suit against the city by advocates on behalf of homeless men who had been turned away from
overflowing shelters led to a court monitored consent decree that guaranteed homeless individuals a right to shelter. This
produced a huge expansion of the public emergency shelter system for individuals and precluded imposing time limits. Without
viable permanent housing alternatives, many homeless individuals have accumulated long histories of shelter stays spanning
years. The system for homeless families has developed very differently. Here advocates responded to the chaos and health
hazards pose

Internet Archive Audio

Featured

Top

Images

Featured

Top

Software

Featured

Top

Books

Featured

Top

Video

Featured

Top

Mobile Apps

Browser Extensions

Archive-It Subscription

Save Page Now

Full text of "Practical Lessons: The 1998 National Symposium on Homelessness Research"

See other formats